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COLLEGE  OF  PHYSICIANS 
AND  SURGEONS 


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Reference  Library 

Given  by 


DR.  H.  E.  HALE 


THE 

ROENTGEN  DIAGNOSIS 

OF  DISEASES  OF  THE 

ALIMENTARY  CANAL 

■-■   '■■'  .  f.iu;n  ■■ 
NEW  YOR;: 

BY 

RUSSELL  D.  CARMAN,  M.  D. 

Head  of  Section  on  Roentgenology,  Division  of  Medicine,  Mayo  Clinic; 

Professor  of  Roentgenology  (Mayo  Foundation),  Graduate 

School  of  Medicine,  University  of  Minnesota 

AND 

ALBERT  MILLER,  M.  D. 

First  Assistant  in  Section  on  Roentgenology,  Division  of  Medicine, 

Mayo  Clinic;  Fellow  in  Roentgenology  (Mayo  Foundation), 

Graduate  School  of  Medicine,  University  of  Minnesota 


WITH  504  ORIGINAL  ILLUSTRATIONS 


PHILADELPHIA  AND  LONDON 

W.   B.  SAUNDERS  COMPANY 

1917 


Copyright,  1917,  by  W.  B.  Saunders  Company 


Printed  in  America 


PREFACE 


Within  a  very  few  years  the  roentgenologic  examination  of 
the  digestive  tract  has  become  an  extraordinarily  efficient  and 
practicable  aid  to  gastro-intestinal  diagnosis.  The  literatm-e  on 
the  subject,  though  extensive,  has  been  widely  scattered  through 
periodicals,  and,  at  the  time  the  preparation 'of  this  book  was 
begun,  no  effort  had  been  made  in  America  to  collect  the  well- 
established  facts  into  a  single  volume. 

Our  intent  has  been  to  select  and  arrange  in  a  systematic 
manner  those  things  which  seem  not  only  to  be  true  but  worth 
while,  and  especially  those  which  we  have  verified  by  experience 
with  a  large  amount  of  material. 

We  have  purposely  avoided  extensive  descriptions  of  appara- 
tus since  this  subject  has  been  rather  full}^  dealt  with  in  several 
comprehensive  pubhcations.  On  the  other  hand,  we  have  given 
detailed  protocols  of  the  findings  in  a  considerable  number  of 
cases  which  have  come  under  our  observation.  Thus  our  hope  is 
that  the  book  will  be  of  some  practical  service  to  our  co-workers 
in  the  field  of  roentgenology.  For  the  sake  of  brevity,  many 
citations  of  authority  have  been  omitted,  but  there  is  no  pretense 
that  the  bulk  of  the  facts  related  are  from  observations  original 
with  us.  In  the  occasional  instances  in  which  we  have  dissented 
from  the  opinions  of  others,  we  have  endeavored  to  quote  oppos- 
ing views  with  fairness  and  without  conscious  implication  that 
our  own  word  should  be  considered  final. 

Because  of  the  lessons  they  may  teach,  our  mistakes 
have  been  recorded  unsparingly,  but  these  errors  should  not  be 
regarded  as  reflecting  on  the  general  efficiency  of  roentgen 
diagnosis. 

To  the  distinguished  brothers  whose  name  designates  the 
clinic  in  which  the  work  has  been  done  and  who  have  given  us 
exceptional  opportunities  for  the  comparison  of  roentgenologic 
and  operative  findings,  to  our  fellow  members  of  the  surgical, 
clinical  and  pathological  staffs,  who  have  heartily  cooperated 
with  us,  to  Mrs.  ]M.  H.  Mellish  of  the  EcUtorial  Department, 
whose  aid  has  been  unflagging,  and  to  our  intimate  associates  in 
the  roentgen  laboratory,  who  have  given  us  generous  help,  our 
obligations  are  gratefully  acknowledged. 

The  Authors. 

Mayo  Clinic, 
Maij,  1917. 

11 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/roentgendiagnosiOOcarm 


CONTENTS 


CHAPTER  I 

Page 

Apparatus 17 

Transformer,  18 — Vertical  Screen  Apparatus,  18 — Foot-switch, 
19— Tube-stand,  20— Table,  20— Tubes,  21— Intensifying  Screens, 
22— Plates  and  Developers,  22. 

CHAPTER  II 

General  Technic 24 

Preparation  of  the  Patient,  24 — Opaque  Salts,  25 — Vehicles,  26 — 
Opaque  Enema,  27 — Quantities  of  Opaque  Salts,  28 — Six-hour 
Meal,  28 — Screen-examination,  29 — Plates,  31 — Case  Records,  32. 

CHAPTER  III 

Interpretation 34 

CHAPTER  IV 

The  Esophagus 39 

Technic  of  Examination,  39 — Anatomical  Memoranda,  4G — Nor- 
mal Esophagus  as  Shown  by  Roentgen  Ray,  47 — Pathologic  Esopha- 
gus as  Shown  by  Roentgen  Ray,  48 — Cardiospasm,  50 — Carcinoma, 
57 — Diverticulum,  62 — Cicatricial  Strictures,  65 — Spasm,  70 — 
Foreign  Bodies,  71 — Miscellaneous  Esophageal  Lesions,  71. 

CHAPTER  V 

The  Stomach 75 

Technic  of  Examinaticjn,  75 — Roentgen  Anatomy,  77. 

CHAPTER  VI 

The  Normal  Stomach 82 

Habitus,  82— The  Abdominal  Wall,  86— Gastric  Tonus,  86— 
Form,  87— Tone,  92— Position,  95— Size,  96— Contour,  97— 
Mobility,  97— Flexibility,  99— Gas-bubble,  99— Secretion,  99— 
Peristalsis,  100 — Motility,  106 — Roentgenologic  Tests  of  Motility, 
110. 

CHAPTER  VII 

The  Abnormal  Stomach 121 

Form  Variations,  121 — Hour-glass  Stomach,  121 — Changes  of 
Contour,  124 — Alterations  of  Tone,  129 — Altered  Position,  131 — 

13 


14  CONTENTS 

Page 
Alteration  of  Size,   132— Altered  Mobility,   132— Lessened  Flexi- 
bility, 133 — Gas-bubble,  133 — Secretion,  134 — Abnormal  Peristal- 
sis, 134 — Disordered  Motilitj^,  139 — Zones  of  Motility  Based  on 
Six-hour  Meal,  146. 

CHAPTER  VIII 

Gastbospasm 153 

Etiology,  162— Differentiation,  162. 

CHAPTER  IX 

Gastric  Cancer 171 

Filling-defects,  173 — Filling-defects  from  Causes  other  than  Can- 
cer, 179 — Alteration  of  Pyloric  Function,  186 — Peristalsis,  189 — 
Altered  Motihty,  189— Lessened  Mobility,  190— Lessened  Flexi- 
bility, 190 — Persistent  Local  Spasm,  191 — Altered  Size  and  Capac- 
ity, 191 — Displacement,  191 — Pathologj^,  192 — Roentgen  Char- 
acteristics of  Fungous  Cancer,  194 — Roentgen  Characteristics  of 
Scirrhous  Cancer,  194 — Mucoid  Cancer,  196 — Carcinomatous 
Ulcer,  196— Operability,  198— Early  Cancer,  202. 

CHAPTER  X 

Fibromatosis  of  the  Stomach 214 

CHAPTER  XI 
Syphilis  op  the   Stomach 219 

CHAPTER  XII 
Various  Benign  Tumor-producing  Lesions  of  the  Stomach.    .    .   241 

CHAPTER  XIII 

Gastric  Ulcer 2.50 

Roentgenologic  Signs  of  Gastric  Ulcer,  252 — The  Niche,  252 — 
Accessory  Pocket,  256 — Contributorj'-  Signs  of  Ulcer,  257 — Spas- 
modic Manifestations:  the  Incisura,  257 — Spasmodic  Hour-glass, 
261 — Other  Forms  of  Spasm,  261 — Organic  Hour-glass,  263 — 
Residue,  264 — Gastric  Hypotonus,  264 — Acute  Fish-hook,  266 — 
Abnormalities  of  Peristalsis,  266 — Tender  Point,  267 — ^Lessened 
Mobility,  267 — Value  of  Sign-groups,  268 — Association  of  Gas- 
tric with  Duodenal  Ulcer,  268 — Carcinomatous  Ulcer,  268. 

CHAPTER  XIV 

Miscellaneous  Gastric  Conditions 292 

Hair-ball,  292— Other  Foreign  Bodies,  297— Diverticula,  297— 
Diaphragmatic  Hernia-and  Elevation  of  Diaphragm  (Eventi-ation), 
301— Gastroptosis,  307. 


CONTENTS  15 

CHAPTER  XV 

Page 

The  Stomach  of  Infants  and  Children 313 

Congenital  Pyloric  Stenosis,  315 — -Aerophagy  in  Infants,  317. 

CHAPTER  XVI 

The  Stomach  after  Operation 319 

Jejunal  and  Gastro jejunal  Ulcers,  326 — Regurgitant  Vomiting  and 
Vicious  Circle,  336 — Recurrence  and  New  Development  of  Lesions 
after  Operation,  341. 

CHAPTER  XVII 

Gall-stones  and  Disease  of  the  Gall-bladder  and  Liver   .    .    .   349 
Gall-stones,  349 — Diseases  of  the  Gall-bladder,  363 — The  Liver, 
370. 

CHAPTER  XVIII 

The  Small  Intestine 374 

The  Normal  Small  Intestine,  374 — The  Abnormal  Small  Intestine, 
380. 

CHAPTER  XIX 

Duodenal  Ulcer 386 

Symptoms,  386 — Pathology,  387 — Technic  of  Examination,  390 — 
Roentgenologic  Signs,  392 — Concurrence  of  Diiodenal  and  Gastric 
Ulcer,  412. 

CHAPTER  XX 

Miscellaneous  Lesions  of  the  Small  Intestine 429 

CHAPTER  XXI 

The  Large  Intestine 434 

Technic  of  Examination,  434 — The  Normal  Colon,  436 — The 
Abnormal  Colon,  443. 

CHAPTER  XXII 

Cancer  of  the  Colon 450 

CHAPTER  XXIII 
Dwerticulitis. 467 

CHAPTER  XXIV 
Tuberculosis  of   the  Colon 481 


16  CONTENTS 

CHAPTER  XXV 

Page 
Chronic  Colitis 486 

CHAPTER  XXVI 

Chronic  Intestinal  Stasis  and  Constipation 493 

CHAPTER  XXVII 

Chronic  Appendicitis 508 

CHAPTER  XXVIII 

Miscellaneous  Lesions  and  Conditions  of  the  Colon 520 

Polyposis,  520 — Anomalies  of  Migration  and  Rotation,  521 — 
Cecum  Mobile,  524 — Jackson's  ]Membrane,  526 — Transposition, 
527 — Intussusception,  528 — Hirschsprung's  Disease  (Megacolon) 
and  Megasigmoid,  529 — Incompetence  of  the  Ileocecal  Valve,  530 — 
Enteroliths,  533 — Foreign  Bodies,  534 — Fistulse,  534 — Rectum, 
537— The  Colon  after  Operation,  537. 


Bibliographic  Index 543 

Index  or  Subjects 547 


THE  ROENTGEN  DIAGNOSIS  OF 
DISEASES  OF  THE  ALIMENTARY  CANAL 

CHAPTER  I 
APPARATUS 

An  adequate  equipment  of  roentgen  apparatus  simplifies 
and  facilitates  the  examination  of  the  digestive  tract  and  for 
such  purposes  can  hardly  be  dispensed  with.  It  is  true  that  in 
this,  as  in  many  other  things,  the  man  counts  for  more  than  the 
machine,  and  the  bulk  of  roentgenologic  knowledge  has  been 
gained  by  those  who  had  to  content  themselves  with  crude 
appliances.  Yet,  modern  apparatus  saves  time  and  labor, 
invites  thoroughness  and  lessens  the  chance  of  error. 

The  coil,  which  superseded  the  static  machine,  is  still  used  by 
many  for  roentgenography  and  to  some  extent  for  roentgeno- 
scopy. It  gives  an  excellent  screen  image,  but  the  interrupter, 
whether  of  the  mechanical,  electrolytic  or  mercury-turbine  type, 
is  a  frequent  source  of  trouble  when  subjected  to  hard  usage. 

In  recent  years,  the  coil  has  generally  yielded  place  to  the 
interrupterless  transformer,  the  development  of  which  has  been 
due  largely  to  American  ingenuity.  Of  interrupterless  ma- 
chines, a  number  of  excellent  makes  are  on  the  market,  and  the 
differences  between  them  are  not  of  great  consequence.  They 
are  adaptable  both  to  roentgenoscopy  and  to  roentgenography 
and  are  dependable  and  economical  in  operation. 

A  varied  assortment  of  vertical  and  horizontal  screen- 
apparatus,  tube-stands,  automatic  plate-changers  for  stereo- 
scopic plates,   and  minor  accessory  ^apparatus  is   obtainable. 

2  17 


18  APPARATUS 

These  accessories  are  constantly  undergoing  modification  and 
improvement,  so  that  the  operator  can  easily  satisfy  his  personal 
preferences  and  requirements.  Extensive  and  detailed  de- 
scription of  apparatus  would  be  superfluous  here,  but  a  few 
remarks  concerning  equipment  may  be  of  practical  aid. 

TRANSFORMER 

The  transformer  for  the  excitation  of  the  roentgen  tube  does 
not  necessitate  the  use  of  a  current-interrupter  on  the  primary 
or  low-tension  side,  as  does  that  of  the  coil;  hence  it  is  com- 
monly termed  an  ''interrupterless  transformer."  Nevertheless, 
interruptions  of  the  current  are  made,  though  on  the  secondary 
or  high-tension  side,  by  a  commutating  switch,  for  the  purpose 
of  utilizing  a  selected  portion  of  the  sine- wave,  and  thus  obtain- 
ing a  pulsating  unidirectional  current.  These  machines  vary 
in  capacity.  It  is  advisable,  however,  to  avoid  extremes,  as 
those  of  medium  capacity  are  best  adapted  to  general  roent- 
genologic work.  At  present,  we  are  using  machines  rated  at  6 
or  8  kilowatts. 

Transformers  are  simple,  practical,  durable  and  efficient,  and 
obviate  the  need  of  a  coil  and  interrupter  with  their  annoyances. 
They  are  made  to  operate  on  either  direct  or  alternating  currents, 
preferably  the  latter.  The  three- wire  alternating-current  sys- 
tem makes  possible  the  use  of  110  volts  through  the  transformer 
for  screening,  and  220  volts  for  making  plates.  Operating 
control-boards  and  protection  screens  are  supplied  with  the 
machines.  If  Coolidge  tubes  are  to  be  used,  the  transformer 
should  be  constructed  so  as  to  back  up  a  spark  of  10  inches  or 
more.  This  requires  a  commutating  disk  of  greater  diameter 
than  those  used  in  the  past,  and  necessitates  an  oil-immersed 
transformer.  The  rheostat  should  have  ample  capacity  to  pre- 
vent overheating. 

VERTICAL  SCREEN  APPARATUS 

For  a  number  of  years  no  one  piece  of  apparatus  has  con- 
cerne  droentgen  work  miore  than  a  suitable  appliance  for  making 


FOOT-SWITCH  19 

fluoroscopic  examinations.  Opinions  regarding  such  instru- 
ments have  been  diversified,  hinging  chiefly  on  the  question  of 
protection,  and  there  have  been  extremists  pro  and  con.  The 
development  of  such  apparatus  has  been  a  matter  of  evolution, 
with  regard  to  adequate  protection,  ease  of  manipulation,  ac- 
cessibility of  parts,  durability,  and  avoidance  of  an  awesome 
appearance. 

Most  of  these  qualities  are  embodied  in  each  of  the  various 
makes  of  vertical  screen  apparatus.  In  general,  such  an  appara- 
tus consists  of  a  counterweighted  tube-box  which  can  be  freely 
moved  laterally  and  vertically  on  the  frame  upon  which  it  is 
mounted.  The  box  is  covered  with  heavy  sheet  lead  and  is 
provided  with  a  door  at  the  side  through  which  an  interchange- 
able tube-holding  board  can  be  taken  in  or  out.  A  small  window 
in  the  front  of  the  box,  opposite  the  target  of  the  tube,  is  covered 
inside  with  a  thin  aluminum  filter.  Over  the  outside  of  the 
window  is  placed  an  adjustable  diaphragm,  usually  of  lead  rein- 
forced with  brass.  The  diaphragm  may  give  either  a  circular 
(iris  type)  or  rectangular  field,  the  latter  being  the  most  gen- 
erally used.  Its  operation  is  controlled  by  an  ingenious 
mechanism  with  a  handle  convenient  to  the  operator's  left 
hand. 

In  front  of  the  tube-box  is  a  high,  wide  shield,  against  which 
the  patient  stands  during  the  examination.  The  shield  may 
be  of  thick,  heavy  metal  with  an  aluminum  or  celluloid  window, 
or  made  wholly  of  celluloid  in  a  metal  frame. 

The  fluoroscopic  screen  is  supported  from  the  tube-box 
either  by  cords  or  by  a  crossarm  with  rigid  suspension  rods. 
The  latter  device  makes  it  possible  to  move  the  tube  and  screen 
in  unison,  and  keep  the  fluoroscopic  field  in  constant  view. 

A  small  turntable,  upon  which  the  patient  stands  while 
being  examined,  is  added  to  the  equipment  of  some  machines, 
and  facilitates  rotation  for  different  angles  of  view. 

FOOT-SWITCH 

All  screen  work  is  done  with  current  ranging  from  1  to  3 
milliamperes  controlled  by  a  graduated  foot-switch. 


20  APPARATUS 

To  operate,  the  main  rheostat  on  the  machine  is  set  to  the 
maximum  desired  for  screen  work,  and  this  maximum  is  ad- 
mitted to  the  screen  tube  by  the  third  pedal  of  the  foot-switch. 
There  are  two  other  pedals  which  admit  respectively  one-third 
and  two-thirds  of  the  maximum  current,  the  regulation  being 
effected  through  an  auxiliary  rheostat  to  which  they  are  con- 
nected. We  are  accustomed  to  using  approximately  3  milli- 
amperes  as  the  maximum,  2  milliamperes  for  the  intermediate, 
and  1  milliampere  as  the  minimum.  These  readings,  however, 
will  fluctuate  somewhat  according  to  the  resistance  of  the  tube. 

The  graduation  by  the  foot-switch  permits  the  operator 
unassisted  to  proportion  the  current  to  the  thickness  of  the 
patient  and  thus  to  give  the  intensity  of  illumination  desired. 
This  arrangement  diminishes  the  likelihood  of  overheating  an 
ordinary  tube,  and  its  convenience  is  obvious. 

In  addition  to  the  current-control  a  light-circuit  is  led  into 
the  foot-switch  and  attached  to  a  make-and-break  switch 
which  controls  the  subdued  illumination  of  the  room  between 
examinations.  This  light  is  also  turned  on  and  off  by  the 
operator's  foot. 

TUBE-STAND 

For  making  plates  of  the  stomach  a  stationary  tube-stand 
is  convenient.  A  fixed,  horizontal,  tubular,  iron  frame  carries 
a  vertical  stand,  which  rides  on  ball-bearings  and  can  be  locked 
at  any  point.  The  tube-holder  and  carriage  are  counter- 
weighted  and  can  be  raised,  low^ered  and  rotated  as  necessary. 
Near  the  end  of  the  stationary  frame  a  light  wooden  table  is 
hinged  on  a  w^all-bracket  so  that  it  can  be  folded  up.  It  is 
fitted  with  an  adjustable  wooden  plaque  for  holding  the  cassette 
when  plating  patients  in  the  standing  position.  By  lowering 
the  table  and  adjusting  the  tube-carrier,  plates  can  be  made 
with  the  patient  recumbent. 

TABLE 

Trochoscopes  and  combined  tables  for  roentgenoscopic  and 
roentgenographic  work  are  obtainable  in  various  designs.     One 


TUBES  21 

of  these  tables,  designed  for  routine  service,  suits  our  own  work 
admirably. 

The  table-top  is  of  standard-make,  tunnel  type,  with  cellu- 
loid window  and  standard  stereoscopic  plate-shifting  mechan- 
ism. The  top  is  supported  by  an  iron  frame,  largely  of  tubular 
construction. 

A  vertical  tube-stand  is  carried  upon  horizontal  rods  attached 
to  the  back  of  the  table,  and  is  fitted  with  ball-bearings  so  that 
it  can  be  easily  shifted.  By  means  of  a  lock  it  can  be  fixed  in 
any  position.  The  tube-holder  is  of  the  usual  type  with  a  lead- 
glass,  bowl-shaped  container  secured  to  a  metal  base-frame, 
and  can  be  raised,  lowered,  tilted  to  any  angle  or  rotated  upon 
its  horizontal  axis. 

The  table  has  been  further  amplified  by  placing  a  movable 
tube-box  beneath  it  for  horizontal  screen-examinatioDs.  The 
tube-box  and  adjustable  diaphragm  are  similar  to  those  used 
on  vertical  screen-apparatus.  The  box  shifts  laterally  on  a 
frame,  and  the  frame  and  box  can  be  moved  lengthwise  on  a 
tubular  track,  with  ball-bearings  for  all  moving  parts. 

The  arrangement  thus  permits  the  use  of  two  x-rs^j  tubes; 
one  on  the  vertical  tube-stand  for  making  roentgenograms,  the 
other  in  the  tube-box  for  screen  work,  the  tubes  being  main- 
tained at  vacua  appropriate  for  their  respective  purposes.  By 
a  device  the  tube-box  carriage  and  the  vertical  tube-stand  can 
be  linked  together  and  moved  in  unison,  so  that  the  screen-field 
can  be  plated  quickly  by  swinging  the  upper  tube  into  place. 

TUBES 

For  plate-making  various  types  of  ordinary  gas  tubes,  both 
American  and  foreign,  can  be  employed.  Greater  differences 
as  to  quality  and  durability  are  observed  between  individual 
tubes  than  between  types.  Preferably  they  should  have  a  7- 
inch  bulb  and  a  heavy  copper  anode  faced  with  tungsten.  For 
screening,  we  have  used  water-cooled  tubes  with  entire  satis- 
faction. The  reservoirs  of  these  tubes  are  of  extra  size,  and 
hold  about  a  pint  of  water,  so  that  heating  is  avoided  even  with 


22  APPARATUS 

prolonged  use.     They  withstand  hard  service  and  with  reason- 
able care  will  last  for  a  considerable  time. 

Recently  Coolidge  has  brought  out  a  tube  of  extraordinary 
efficiency.  It  is  exhausted  to  a  much  higher  degree  than  the 
ordinary  tube.  The  cathode  is  a  tungsten  filament  in  the  shape 
of  a  flat,  closely  wound  spiral,  and  is  heated  by  current  either 
from  a  storage  battery  or  a  small  transformer,  with  rheostat 
control.  The  storage  battery  can  be  used  whether  the  main 
current  supply  is  either  direct  or  alternating,  but  in  the  latter 
case,  some  form  of  rectifier  is  necessary  for  recharging  the 
battery.  The  small  transformer  is  of  use  only  with  alternating 
current.  Electrons  are  liberated  from  the  cathode  in  propor- 
tion to  the  degree  of  heat,  and  the  tube-penetration  can  thus  be 
controlled  with  precision.  The  tube  is  coming  into  common 
use  for  screening,  plating  and  therapeutic  purposes.  It  is  very 
durable  and  seems  to  be  ideal.  Our  own  experience  with  it 
has  been  highly  satisfactory. 

INTENSIFYING  SCREENS 

Intensifj^dng  screens  are  distinctly  advantageous  because 
they  shorten  the  time  of  exposure.  Fortunately,  there  are 
American  screens  quite  as  good  as  the  foreign  screens,  if  not 
better.  In  using  the  screen,  cleanliness  and  careful  loading, 
with  firm  contact,  must  be  observed.  The  cassette  should  be 
of  light  weight,  thin,  durable,  light-proof  and  easily  loaded. 
Cassettes  made  of  aluminum  are  preferable  to  those  of  wood. 

PLATES  AND  DEVELOPERS 

The  best  plates  are  those  which  have  unvarying  uniformity, 
fair  latitude,  moderate  speed  and  good  keeping  qualities  and 
are  free  from  blemishes.  Reasonable  latitude  is  desirable  in 
order  that  slight  variation  in  the  time  of  exposure  will  not 
impair  the  roentgenogram.  The  greater  the  speed,  the  less  is 
this  latitude;  hence  it  is  better  to  choose  a  plate  that  is  neither 
extremely  fast  nor  extremely  slow.     Manufacturers  recommend 


PLATES   AND   DEVELOPERS  23 

developers  which  are  best  suited  for  their  plates,   and  their 
advice  should  be  followed. 

Questions  are  frequently  asked  as  to  the  length  of  exposure 
necessary  to  produce  a  satisfactory  roentgenogram.  This 
depends,  as  the  operator  will  soon  learn,  upon  the  capacity  of 
his  machine,  the  voltage,  the  milliamperage  passing  through 
the  tube,  the  speed  of  the  plate,  the  tube  distance,  the  density 
of  the  part  and  whether  or  not  an  intensifying  screen  is  used. 
Therefore,  the  beginner  should  not  hastily  blame  his  equipment 
nor  be  surprised  at  his  early  failures,  for  they  can  be  overcome 
only  by  experience. 


CHAPTER  II 
GENERAL  TECHNIC 

In  order  that  comparisons  may  be  made  on  a  uniform  basis, 
the  roentgenologist  should  have  a  customary  routine.  While 
it  would  be  desii'able  for  all  roentgenologists  to  employ  identical 
methods,  efforts  in  this  direction  have  thus  far  been  fruitless. 
However,  the  individual  examiner  will  find  it  advantageous  to 
choose  and  follow  as  faithfully  as  possible  the  method  which 
to  him  seems  best.  His  routine  should,  of  course,  be  flexible 
enough  to  vary  in  exceptional  circumstances.  Indeed,  some 
degree  of  inventiveness  and  ingenuity  is  requisite  in  deahng 
with  extraordinary  circumstances,  but  in  forming  opinions 
allowance  should  be  made  for  am^  departure  from  the  accus- 
tomed procedure. 

It  should  he  kej)t  constantly  in  mind  that  many  of  the  conclu- 
sions herein  stated  are  based  on  the  routine  descrihed.  Those  who 
attempt  to  folloiv  this  hook  should  adhere  with  reasonable  fidelity 
to  the  technic  as  related.  Otherwise  there  may  he  annoying  dis- 
crepancies in  the  results.  On  the  other  hand,  it  should  also  be 
emphasized  that  rigid  adherence  to  any  routine  will  not  alone  make 
diagnoses;  that  interpretation  of  findings,  which  can  be  learned  only 
by  experience,  is  quite  as  important  as  technical  methods;  and  that 
the  beginner  must  expect  at  least  a  few  disappointments  at  first. 

Preparation  of  the  Patient. — One  of  the  most  important 
roentgenologic  signs  of  a  lesion  in  the  digestive  tract  is  deformity 
of  contour,  and  such  deformity  may  be  imitated  by  the  presence 
of  food  or  fecal  material.  The  stomach,  when  examined,  should 
be  empty;  ample  time  should  be  allowed  for  evacuation  of  the 
last  meal  taken  prior  to  the  examination,  and  the  patient  should 
abstain  from  food  until  the  examination  is  finished.     The  ma- 

24 


OPAQUE    SALTS  25 

jority  of  our  patients  come  to  us  directly  from  the  gastroenter- 
ologist  after  tubing  and  lavage,  and  while  as  a  rule,  these  latter 
procedures  are  not  a  necessary  prelude,  they  insure  a  more 
thorough  evacuation  of  food-bits  and  secretion  in  obstructive 
cases,  and  clear  out  mucus  and  hemorrhagic  detritus  from  the 
craters  of  gastric  ulcers.  If  the  colon  is  to  be  examined  by  the 
opaque  clysma,  the  patient  should  be  previously  purged  with 
oil  or  a  saline,  preferably  oil,  and  should  flush  out  the  bowel  with 
a  cleansing  enema  shortly  prior  to  the  examination. 

In  exceptional  instances  where  motility  is  especially  con- 
cerned, as  in  cases  of  suspected  stasis,  a  separate  examination 
under  the  patient's  accustomed  conditions  and  without  purga- 
tion, enemas  or  fasting,  may  be  conducted.  Such  findings 
should  be  compared  with  each  other,  and  not  with  those  ob- 
tained after  preparatory  measures. 

Opaque  Salts. — In  the  early  attempts  at  visualization  of 
the  human  digestive  tract,  bismuth  subnitrate  was  tried.  Its 
occasional  toxicity  led  to  some  fatalities  and  it  was  soon  aban- 
doned. Since  then  bismuth  subcarbonate  has  been  extensively 
employed.  It  has  been  claimed  (and  disputed)  that  its  alka- 
linity somewhat  depresses  peristaltic  activity.  The  oxychloride 
of  bismuth,  which  is  sometimes  used,  is  a  trifle  lighter  than  the 
subcarbonate,  and  hence  a  little  more  easily  held  in  suspension. 
Peristalsis,  as  seen  with  the  oxychloride,  is  perhaps  a  trifle 
more  active  than  that  seen  with  the  subcarbonate.  Both  the 
subcarbonate  and  oxychloride  are  harmless  even  in  much  larger 
quantities  than  ordinarily  administered.  The  oxides  of  zir- 
conium (kontriastin)  and  thorium,  and  the  magnetic  oxide  of 
iron  have  been  used  to  a  limited  extent. 

Chemically  pure  barium  sulphate  at  less  than  a  tenth  the 
cost  of  bismuth  salts  is  equally  satisfactory  and  is  now  generally 
employed.  We  have  adopted  it  for  both  the  opaque  meal  and 
the  enema.  It  must  be  free  from  any  soluble  salts  of  barium 
which  are  toxic;  it  should  be  in  a  finely  divided  state,  and  can 
be  obtained  in  this  condition  from  manufacturers.  It  is  harm- 
less, tasteless,  and  does  not  inhibit  or  unduly  stimulate  peris- 


26  GENERAL  TECHNIC 

talsis,  but  is  passed  through  the  digestive  tract  more  rapidly 
than  bismuth  salts. 

Attempts  have  often  been  made  to  visualize  the  digestive 
canal  after  inflation  with  air  or  gas.  Notwithstanding  the  fact 
that  pronounced  lesions  have  occasionally  been  demonstrated 
in  this  manner,  the.  method  is  far  less  certain  than  the  use 
of  opaque  meals  and  enemata,  and  hardly  deserves  serious 
consideration. 

Vehicles. — In  selecting  a  medium  for  the  administration  of 
opaque  salts,  a  wide  latitude  of  choice  is  offered.  Any  of  the 
commonly  used  vehicles  may  be  employed  with  satisfaction, 
but  it  is  desirable  that  the  mixture  shall  have  the  following 
qualities : 

1.  It  should  be  palatable. 

2.  It  should  be  sufficiently  viscid  to  hold  the  opaque  salt  in 
good  suspension. 

3.  It  should  not  be  too  thick  to  fill  small  recesses. 

4.  It  should  not  unduly  stimulate  gastric  secretion. 

5.  It  should  neither  accelerate  nor  retard  motility. 

The  vehicles  commonly  used  include  water,  milk  (plain, 
condensed  or  fermented),  mucilage  of  acacia,  potato-starch, 
bread-and-milk,  corn-starch-pap,  gruels  and  various  cereals. 
Each  of  these  has  its  advantages  and  disadvantages,  depending 
on  the  purpose  in  view.  For  the  six-hour  opaque  meal,  a 
cereal,  such  as  one  of  the  wheat  breakfast  foods,  is  desirable.  At 
the  beginning  of  the  screen-examination,  a  little  plain  water  and 
barium  (or  bismuth)  can  be  given  to  advantage.  By  palpation 
it  can  easily  be  shifted  into  all  parts  of  the  stomach,  thus  out- 
lining its  borders.  Being  of  thin  consistency  it  will  enter  small 
niches  and  ulcer-pockets,  and  as  it  does  not  excite  the  pyloric 
reflex  can  be  expressed  into  the  duodenum,  thus  establishing 
the  site  of  the  pylorus  and  outlining  the  duodenal  bulb.  For 
complete  filling  of  the  stomach  to  finish  the  screen-examination 
and  for  roentgenography,  fermented  milk,  which  may  be  ob- 
tained either  in  bottled  proprietary  form  or  can  be  made  by 
adding  culture-tablets  to  whole  milk,  is  admirable.     This  is 


THE    ENEMA  27 

relished  by  most  patients,  holds  the  opaque  salt  in  good  suspen- 
sion, and  does  not  affect  the  motor  functions.  Mucilage  of 
acacia,  freshly  made  from  the  powdered  gum,  is  effective.  It 
is  especially  useful  in  examining  the  esophagus.  Condensed 
milk  holds  up  barium  fairly  well  and  is  palatable,  but  owing  to 
its  fat,  markedly  diminishes  motor  activity.  Thick  gruels  of 
wheatmeal  or  oatmeal  are  often  used  in  esophageal  work. 

A  pap  made  up  either  with  potato-starch  or  corn-starch  is 
an  excellent  vehicle.  We  have  used  both  extensively,  but  have 
of  late  given  preference  to  the  corn-starch  because  of  its  more 
pleasant  taste.  The  starch  is  obtainable  everywhere  in  pound 
cartons.  To  prepare  the  pap  in  quantity  the  following  recipe 
may  be  used: 

Nine  ounces  of  corn-starch  dissolved  in  14  ounces  of  cold 
water  is  poured  into  6  quarts  of  boiling  water.  Forty-five 
ounces  of  barium  sulphate  is  stirred  into  a  thin  paste  with  20 
ounces  of  hot  water;  allowed  to  boil  for  three  or  four  minutes, 
and  is  then  added  to  the  starch-pap.  The  whole  mixture  is 
stirred  well  and  allowed  to  boil  for  five  minutes  slowly.  After 
cooling,  3^^  ounce  of  vanilla  extract  is  added.  Syrup  of  rasp- 
berry in  larger  quantity,  or  other  flavoring,  can  be  used  as 
desired.  The  mixture  will  keep  well  on  ice  for  two  or  three  days. 
On  standing  a  scum  may  collect;  this  should  be  removed.  The 
customary  portion  for  each  patient  is  12  ounces  of  the  mixture, 
which  amount  contains  approximately  3  ounces  of  barium. 

The  Enema. — The  essentials  of  an  opaque  enema  are: 

1.  That  the  mixture  shall  not  be  irritating  to  the  bowel. 

2.  That  it  shall  be  sufficiently  large  to  fill  the  entire  colon. 

3.  That  it  shall  be  sufficiently  ffuid  to  flow  freely,  yet  thick 
enough  to  keep  the  barium  (or  bismuth)  well  distributed. 

Any  of  the  opaque  salts  may  be  used  as  a  base  but  the  inex- 
pensive barium  sulphate  is  employed  most  generally.  In  some 
instances  bolus  alba  (kaolin)  is  added,  500  gm.  to  3  pints. 

For  mediums,  mucilage  of  acacia,  fermented  milk,  condensed 
milk,  mucilage  of  tragacanth,  starch  and  other  vehicles  are 
employed.     Any  of  these  or  combinations  of  them  can  be  used 


28  GENERAL   TECHNIC 

satisfactorily.  The  starch  solution  has  the  occasional  disadvan- 
tage of  becoming  lumpy  on  standing  and  thus  obstructing  the 
enema  tube.  A  combination  of  mucilage  of  acacia,  condensed 
milk  and  barium  (described  in  the  chapter  on  The  Large  Intes- 
tine) makes  an  excellent  enema. 

Quantities. — The  quantity  of  opaque  salts  used  for  the  meal 
by  different  roentgenologists  varies  markedly,  ranging  from  1 
to  6  ounces  at  a  single  administration,  and  the  total  amount  of 
ingesta  may  be  from  6  to  30  ounces.  The  proportion  by  weight 
of  opaque  salt  to  medium  varies  from  10  to  25  per  cent.  As  a 
general  rule,  it  will  be  found  that  mixtures  containing  less  than 
10  per  cent  of  the  opaque  salt,  especially  barium,  are  not  reliable 
for  visualizing  lesions  on  the  screen  or  plate. 

There  are  wide  differences  among  various  examiners  in  the 
manner  and  time  of  observation.  One  routine  frequently  em- 
ployed consists  in  the  administration  of  a  single  opaque  meal, 
the  phenomena  of  its  progress  through  the  digestive  canal 
being  noted  at  successive  intervals  by  screening  and  plating. 
By  the  double-meal  method  as  used  by  Haudek,^  which  we  have 
preferred  to  follow,  one  meal  is  given  chiefly  for  the  purpose 
of  testing  motility,  and  this  is  followed  by  another  six  hours 
later,  at  which  time  the  roentgenologic  examination  is  made. 

The  Six -hour  Meal. — As  employed  by  Haudek,  the  six-hour 
meal  was  made  up  originallj'  T\-ith  bismuth  subcarbonate. 
Haudek' s  wide  experience  convinced  him  that  a  distinct  residue 
from  this  meal  in  the  stomach  after  six  hours  was  usually  of 
pathologic  significance,  although,  in  some  instances,  he  beheved 
it  might  result  from  gastric  atony.  For  four  years  or  more  we 
have  used  barium  sulphate  in  the  meal,  and  as  barium  leaves 
the  stomach  earlier  than  bismuth,  a  residue  from  the  former 
has  even  greater  import.  The  various  causes  of  such  a  residue 
are  hereinafter  enumerated.  In  our  habitual  routine,  the  meal 
consists  of  2  ounces  of  barium  sulphate  in  4  ounces  of  cooked 
cereal,  to  which  a  httle  skimmed  roilk  and  sugar  are  added. 
Objection  has  been  made  that  in  those  cases  in  which  the  six- 
hotu-  meal  has  advanced  into  the  transverse  colon  or  splenic 


THE    SCREEN-EXAMINATION  29 

flexures  it  may  interfere  with  the  screen  and  plate  examination 
of  the  stomach.  This  seldom  happens,  and  when  it  does,  re- 
examination can  be  made  after  the  colon  is  empty.  Personally, 
we  would  rather  risk  the  necessity  of  a  second  examination 
than  do  without  the  six-hour  meal. 

The  principal  advantage  of  the  six-hour  meal  is  the  saving  of 
time  to  the  examiner  and  of  annoyance  to  the  patient  entailed 
by  repeated  screening  or  plating.  It  not  only  shows  whether 
the  stomach  is  able  to  clear  itself  within  the  given  time,  but  also 
by  its  position  and  distribution  in  the  intestine  gives  gross 
information  as  to  intestinal  motility.  Its  use  is  based  on  the 
theory  that  the  exact  emptying-time  of  the  stomach  is  less  im- 
portant than  the  fact  that  a  liberal  time-limit  for  evacuation  is 
or  is  not  exceeded.  It  is  quite  possible  that  a  more  refined  study 
of  the  gastric  clearance-time  will  be  of  greater  diagnostic  aid. 
In  estimating  the  significance  of  slighter  variations  in  the  time 
of  emptying,  however,  the  numerous  physiologic  and  pathologic 
factors  affecting  motility  will  need  to  be  carefully  weighed. 

The  Screen-examination. — We  believe  that  the  advantages 
of  the  screen  in  the  examination  of  the  digestive  tract  can  hardly 
be  too  strongly  emphasized.  Only  by  its  use  can  exact  informa- 
tion be  obtained  as  to  mobility  and  flexibility,  the  phenomena  of 
peristalsis  and  antiperistalsis,  the  nature  and  permanence  of 
irregularities  of  contour,  and  the  effects  of  palpation,  respiratory 
movement  and  varying  positions.  All  changes  can  be  seen  at 
every  instant,  in  the  order  of  their  succession,  at  any  desired 
angle,  and  in  these  respects  a  few  minutes  of  screening  is  equiva- 
lent to  hundreds  of  plates.  The  screen  also  affords  convenient 
opportunity  for  inspecting  the  chest  and  abdomen  for  numerous 
lesions  which  may  affect  the  digestive  tract  reflexly. 

A  very  necessary  part  of  roentgenoscopic  technic  is  the  proper 
preparation  of  the  observer's  eyes.  To  secure  a  maximum 
of  dark-accommodation  and  retinal  perception  the  examiner 
should  be  in  the  darkened  screen-room  for  ten  or  fifteen  minutes 
before  beginning  his  work.  The  maintenance  of  this  accommo- 
dation is  furthered  by  the  use  of  subdued  illumination  whenever 


30  GENEEAL   TECHNIC 

light  is  required  at  intervals,  and  the  use  of  smoked  glasses 
during  these  periods.  For  the  room-light  a  color  in  the  red 
portion  of  the  spectrum  is  preferred,^  and  is  best  secured  indirectly 
by  reflection  from  a  tinted  ceiling.  The  walls  may  be  finished 
in  the  same  color. 

Male  patients  should  be  stripped  to  the  hips.  Women  may 
be  allowed  to  wear  a  kimona  of  thin  material,  but  this  should 
be  devoid  of  buttons  or  ornaments,  and  the  underskirts  should 
be  dropped  below  the  abdomen. 

Palpatory  manipulation  is  a  very  essential  part  of  the  roent- 
genoscopic  procedure  and  should  never  be  omitted.  Not 
infrequently  the  patient,  made  apprehensive  by  his  somber 
surroundings,  tenses  his  abdominal  muscles  so  that  palpation 
is  ineffective.  This  difficulty  can  usually  be  overcome  by  quiet- 
ing the  patient's  fears.  He  should  also  be  required  to  bend  his 
head  forward,  drop  his  shoulders,  allow  his  arms  to  hang  hmply, 
and  breathe  deeply  with  open  mouth. 

Mindful  of  the  numerous  disasters  which  have  befallen  the 
pioneers  in  roentgenology,  many  have  a  lively  sense  of  possible 
danger  to  the  operator  from  the  use  of  the  screen.  We  can  say 
only  that  after  several  thousand  examinations  with  the  appa- 
ratus heretofore  described,  we  have  experienced  thus  far  no 
evil  effects.  Haudek  also  states  that  he  has  made  12,000 
screen-examinations  without  sustaining  injury. 

The  tendency  of  the  rays  to  produce  sterility  is  well  known, 
and  perhaps  may  not  be  overcome  by  the  usual  protective 
measures  if  exposures  are  long  or  frequently  repeated.  Certain 
blood-changes  also  have  been  noted  by  Portis  and  others.  But 
workers  with  the  ray  who  take  the  customary  precautions  are 
not  likely  to  develop  roentgen  dermatitis  or  carcinoma.  The 
operator  should  endeavor  to  secure  the  greatest  amount  of 
protection  consistent  with  efficiency.  He  should  wear  gloves 
of  leaded  rubber  or  other  opaque  material,  and  should  protect 
the  genitalia  with  an  apron  of  leaded  fabric.  If,  with  all  these 
measures,  he  is  still  dubious  of  his  safety,  he  should  test  for 
leakage  with  radiographic  films,  plates  or  pastilles. 


Case  No.  A Sex 


-  Age.-. 


[  Total  Acidity 

Free  Hel. 

Comb.  Acids 
[  Lactic  Acid 


Food  remnants 
Oppler-Boas 
Yeasts 
Sarcines 


HabituB 

N.           E. 

Residue 

0.            1.            2. 

3.           4. 

Head 

I.           C.           H.  F. 

T.  C.           S. 

F.           D. 

Peristalsis 

Nor.           Active 

Vigorous 

Not  Seen 

Bulb 

Seen           Size        1       2 

3           Reg. 

Irreg. 

Duod.  Visualized           Immediately 

Delayed 

Not  Seen 

Antrum 

Seen           Regular 

Irregular 

Not  Seen 

Mobility  Free  Slightly  Fixed  Fixed 

Filling  Defects  Card  Media.  Pylorica  GO. 

Incisura  Card.  Media.  Pylorica  Transient 

Hour-Glasa  Stomach  Organic  Intermittent 

Tender  Point  L.  C.  Duod.  G.  B.  McB. 


Niche 

Diverticulum . 


Epig. 


Increased  Severity... 


— radiates-.. 


Trouble— Esopliagus,      Stomach,      Bowels,      Duration _ 

Pain— Slight,  severe,  dull,  gnawing,  fullness,  distress,  where - 

continuous „,_  intennittent - — frequency... 

after  meals _ ....- „ „ ™  night,  time 

aggravated  by  food,     quantity,      solid,     acid,      fats,      fibrous;         relieved  by  food,     soda,      belching,      vomiting. 

Stomach  feels  better  full,  formerly,  now;  empty,  formerly,  now. 


,.  duration — 
.-  any  time.- 


Vomito— Rarely,  occasionally,  often.... blood, 

Sour  Stomach -Gas Jaundice,  si.,  distinct Cramps Morph. 

B.  M.— Regular,  constipation,  diarrhoea,  black,  clay,  blood,  mucus.  Typhoid „ 

Weight— Increasing,  stationary,  off _....-,Ibs.  in....-^™^ — Reduced  diet - - - 

General  Condition— Good,  fair,  poor,  weakness,  emaciation,  pallor,  appetite. — ■ 

Operations: 


mucus,  bile,  forced,  delayed,  tube- — 


Fig.  1. — Scratch  sheet  for  fluoroscopic  findings  and  clinical  data. 


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(9)Enteroptosis  (lO)Fistula  (Il)PoreignBody  {l2)Hcmi(idiBphr.  (ia)Hira<:!isprung's  Dis.  (14 
(ISjlMompBlencG  (16) Indc terra inale  (ITjJnckaon'fl  M.  (l8)Kink  (l9)Negativo         (^9)^ 

(21)Nonnal        (M)Oba  true  Hon  (23)Ptosia        (24)  Redundancy  (£6)Spaflin  (26)Spaatid^ 

(28)Stcnosis         (29)StrEcturo         (aO)SyphiN3         (3l)Transpoaition  (32)  Tuberculosis         (33)Tumor 

(35)  Cardiospasm        (3S)  Gall -a  tones  (37)FiJlingQefccC 

(A)E3ophnEU3         (B)SWmacl.  (C)Cardia  (D)Medii  (E)PaR  pylor.  (DPylor 

(G)  Greater  cur  V.      (H)  Leaser  curv.      (I)Duodonum      (J)Je]unum      (K)neam      (L)Ileo-cecal  Val 
(M)Colo.i         (N)Cocam  (O)AscendirB  Colon  (P)Hepatk  Flexure  (QjTransverae  Goli 

(B)Splcnic  Fiexuro        (S) Descending  Colon        (DSiemold  Floxure        (U)RcctDm 


-hHyperlonic       oOrtbotonic       yllypoton 
DEFECTS -cCard.    mMed.    ppyl.    gGre 


d.    raMed.     ppyl.    nNnrrow    bBroad    dD 
(c)Completenflor   six  hra.        ntncomplet 


rRapid        sSloiv        TFrcqucn 


1  PHOTOGRAPHS.-yYf? 


Fio.  2. — Perm  anon  I 


PLATES  31 

As  for  the  patient,  his  safety  is  fairly  assured  by  the  protect- 
ive features  of  the  apparatus  and  by  the  brevity  of  the  exami- 
nation. With  reasonable  care  as  to  the  character  of  the  tube 
(say  one  backing  up  4  to  6  inches  on  the  parallel  spark-gap  at  3 
milliamperes,  110  volts),  no  patient  will  be  harmed.  Two  or 
three  milliamperes  on  the  tube-circuit  will  usually  suffice,  but 
for  thick  patients  4  or  even  5  milliamperes  may  be  required. 

The  time  necessary  for  roentgenoscopic  investigation  will 
not  usually  exceed  ten  minutes.  Occasionally,  however,  when 
peristalsis  especially  is  to  be  studied,  a  little  more  time  will  be 
required.  By  judicious  use  of  the  foot-switch,  turning  on  the 
rays  only  as  needed,  the  aggregate  of  exposure  can  be  consider- 
ably lessened. 

Plates. — After  the  examiner  has  acquired  some  proficiency 
with  the  screen,  he  will  occasionally  be  inclined  to  dispense  with 
plates,  especially  in  the  apparently  normal  cases  when  the 
patient  is  thin,  the  screen  image  sharp,  and  the  clinical  history 
negligible.  But  it  is  never  wholly  safe  to  do  this,  and  at  least 
two  or  more  plates  should  be  made  in  every  case.  Plates  show 
minute  deformities  which  cannot  be  detected  on  the  screen, 
may  be  studied  at  leisure,  and  may  be  filed  for  future  reference. 
When  the  result  of  an  examination  is  indecisive,  an  increased 
number  of  plates  may  give  further  assistance.  They  can  be 
made  either  in  rapid  succession  or  at  longer  intervals.  Multiple 
plates  are  especially  useful  in  studying  the  stomach,  the  pyloric 
region  and  the  duodenum,  when  a  lesion  is  strongly  suspected 
but  cannot  be  determined  in  the  ordinary  way. 

Lewis  Gregory  Cole,^  has  elaborated  the  multiple-plate 
method  and  applied  to  it  the  term  "serial  radiography."  He 
employs  a  table  equipped  with  a  plate-changing  device  beneath 
the  table-top  which  permits  the  making  of  multiple  plates  with- 
out disturbing  the  patient. 

In  published  discussions  of  gastric  roentgenology  it  is  occa- 
sionally intimated  that  the  screen  and  plate  are  rivals.  This  is 
a  misapprehension.  Rather  should  they  be  Considered  as  indis- 
pensable complements  to  each  other  in  every  complete  exami- 


32  GENEEAL   TECHNIC 

nation.  Personally,  we  have  always  used  both  methods,  and 
would  fear  to  discard  either.  Cases  are  frequently  met  with  in 
which  sometimes  one,  sometimes  the  other,  alone  elicits  the 
information  sought. 

The  positions  employed  for  particular  purposes,  suitable 
sizes  of  plates,  and  other  details  are  described  elsewhere.  We 
find  some  advantage  in  the  intensifying  screen  and  use  it  regu- 
larly. But  as  to  this  and  many  other  technical  refinements, 
such  as  the  tube-distance,  the  milliamperage,  length  of  exposure, 
etc.,  no  hard  and  fast  rules  can  be  laid  down,  and  every  roent- 
genologist determines  these  things  according  to  his^  own  judg- 
ment and  the  character  of  his  equipment.  I 

Stereoscopic  plates  are  striking  in  their  appearance  and  are 
somewhat  more  informative  than  single  roentgenograms,  but  they 
are  rather  superfluous  if  a  careful  screen  examination  is  made. 

Roentgen  kinematography  has  been  tried  in  a  few  instances 
with  fairly  satisfactory  results.  It  is  not  practicable  as  a  routine 
and  does  not  possess  any  extraordinary  advantages  over  roent- 
genoscopy. 

Records. — The  benefits  derived  from  a  systematic  record 
of  case  observations  more  than  compensate  the  examiner  for 
the  time  required  to  register  his  findings,  no  matter  whether  he 
sees  1  or  20  cases  a  day. 

Such  a  system  not  only  keeps  the  material  in  shape  for  ready 
comparison,  but  promotes  orderly  thoroughness  of  observation, 
thus  preventing  the  errors  often  consequent  on  haphazard 
investigation. 

Besides  the  usual  series  of  card  indices,  our  own  records  con- 
sist of  a  fluoroscopic  sheet,  a  permanent  record  sheet  and  a 
recapitulation  sheet.  The  sheet  which  is  used  in  the  screen- 
room  (Fig.  1)  has  a  brief  form  for  the  sahent  facts  of  the  chnical 
history  and  the  gastric  analysis,  besides  blanks  for  entry  of  the 
screen  findings.  Most  entries  can  be  made  simply  by  checking 
or  underscoring  the  item. 

In  the  blank  square  the  examiner  notes  his  diagnostic  opin- 
ion or  the  most  significant  facts.     Subsequently,  the  notations 


SiiEET  A.    Page 


DIGESTIVE  TRACT,  X-RAY 


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REFEEENCES  33 

on  this  sheet  are  compared  with  the  plate  findings,  and  a  final 
report  is  entered  on  the  permanent  record  sheet. 

The  permanent  record  sheet  may  seem  rather  elaborate  and 
cumbersome,  but  it  can  easily  be  filled  out,  nearly  all  the  data 
being  entered  by  underscoring  (Fig.  2).  Some  of  the  items  are 
seldom  used,  but  have  been  included  in  order  that  the  record 
may  cover  a  wide  range  of  possibilities. 

The  diagnostic  division  provides  for  an  abbreviated  cipher 
of  the  diagnostic  opinion.  Pathologic  conditions  are  denoted 
by  numbers  and  the  parts  involved  by  capital  letters.  By 
combining  a  number  and  a  letter  the  diagnosis  can  be  condensed 
within  small  space. 

Before  each  item  in  the  body  of  the  sheet  is  a  small  letter. 
If  the  item  is  underscored,  this  letter  is  entered  in  the  corre- 
sponding column  of  the  recapitulation  sheet.  This  is  a  device  of 
H.  S.  Plummer's  and  is  applied  to  many  of  the  records  in  the 
Mayo  Clinic. 

The  recapitulation  sheet  facilitates  a  rapid  summary  of  case 
findings  (Fig.  3).  By  tracing  a  single  column  on  this  sheet  the 
percentage  of  occurrence  of  a  given  observation  can  readily  be 
found;  thus  also  the  incidence  of  various  combinations  can  be 
determined  quickly. 

REFERENCES 

1.  Haudek,  M.:  "Die  Technik  und  Bedeutung   der  rad.  Motilitats 

Prufung."  Ver.  xxix  Deutsch.  Kong.  f.  Int.  Med.  J.  F. 
Bergmann,  Wiesbaden,  1912,  143-148. 

2.  Petit,  H.:  "Extraction  rapide  des  projectiles  de  guerre  par  le  chir- 

urgien  seul  a  I'aide  de  la  lumiere  rouge  et  des  reperages  suc- 
cessifs  sur  I'ecran  radioscopique."  Paris  Medical,  1916,  vi,  76. 
Abst.  Jour.  A.M. A.,  1916,  Ixvii,  707. 

3.  Haudek,  M.:  Personal  communication,  May,  1913. 

4.  PoRTis,  M.  M. :  "Blood  Changes  in  Workers  with  the  Roentgen  Ray 

and  Apparatus  for  Protection."     Jour.  A.M.  A.,  1915,  Ixv,  20-21. 

5.  Cole,  L.  G.:  "Serial  Radiography  in  the  Differential  Diagnosis 

of  Carcinoma  of  the  Stomach,  Gall-bladder  Infection,  and 
Gastric  or  Duodenal  Ulcer."  Arch.  Roentgen  Ray,  1912-13, 
xvii,  172-181. 

3 


CHAPTER  III 
INTERPRETATION 

The  roentgenologic  examination  of  the  digestive  tract  is  not  a 
mysterious  art  requiring  extraordinary  talents.  Neither  is  it  a 
simple  diagnostic  method  which  can  be  learned  in  a  day.  Its 
successful  employment  demands  industry,  experience,  judgment 
and  care,  just  as  any  other  procedure  in  medicine — no  more, 
but  no  less. 

The  roentgenologist  has  to  deal  with  shadows  and  shadow 
defects  as  signs  of  normal,  reflex  and  pathologic  conditions. 
These  signs  vary  in  their  frankness  and  degree.  Some  of  them 
are  more  or  less  direct,  showing  as  definite  and  permanent 
additions  to  or  subtractions  from  the  normal  contour.  Others 
are  rather  indirect,  revealing  only  perversion  of  function,  and 
the  seat  and  nature  of  the  pathologic  change  can  only  be  inferred. 
Indirect  signs  have  different  values  at  different  times,  singly 
and  in  combination.  It  is  impossible  to  put  into  words  the 
exact  worth  of  these  signs  in  their  fluctuating  grades.  That 
can  be  learned  only  by  actual  experience  with  adequate  material 
and  by  following  cases  to  the  operating  room  and  the  post- 
mortem table.  The  most  painstaking  description  of  a  lesion  is 
not  equivalent  to  seeing  it  oneself  in  the  opened  belly,  and  only 
by  this  sort  of  vision  can  one  obtain  a  proper  understanding  of 
roentgen  diagnosis  or  confidence  in  the  method.  Familiarity 
with  reflex  conditions  and  the  protean  forms  of  spasm  is  abso- 
lutely essential. 

The  maintenance  of  a  conservative  attitude  in  this  work  is 
especially  necessary,  and,  at  the  same  time,  especially  difficult. 
The  veteran  roentgenologist,  as  well  as  the  novice,  is  tempted  to 
see  too  much  rather  than  too  little.  Once  the  observer  has 
acquired  some  familiarity  with  his  work  he  will  find  that  direct 

34 


INTERPRETATION  35 

signs  of  lesions  will  be  manifest  quickly  or  not  at  all.  He  should, 
of  course,  take  sufficient  time  to  examine  his  patient  in  all  the 
routine  particulars,  but  unduly  prolonged  examinations  dull  the 
sense  of  proportion,  and  a  perfectly  innocent  stomach  may  seem 
guilty  to  ungenerous  scrutiny. 

Failure  to  discover  a  lesion  by  the  roentgen-ray  is  often 
pardonable,  but  the  subjection  of  a  patient  to  needless  operation 
upon  trivial  roentgen  evidence  alone,  is  not  readily  forgiven 
by  those  concerned.  Common  sense  has  been  defined  as  the 
ability  to  distinguish  the  important  from  the  unimportant,  and 
in  this  meaning  every  diagnostician  has  an  abiding  need  of 
common  sense. 

There  are  two  very  practical  checks  against  error  which  the 
examiner  may  employ,  namely,  reexamination  and  the  giving 
of  antispasmodics  in  cases  in  which  spasm  is  suspected.  In  all 
doubtful  cases  one  or  both  of  these  tests  should  be  applied. 

By  any  means  of  diagnosis,  exceptional  cases  are  found  which 
are  quite  at  variance  with  the  common  rule.  Naturally,  these 
are  tremendously  impressive,  so  impressive  that  it  is  difficult 
thereafter  to  avoid  being  unduly  alert  for  them.  The  only 
safe  way  is  to  hold  fast  to  the  rule  and  regard  exceptions  with 
doubt. 

The  statement  of  W.  J.  Mayo,  that  only  about  one  person  in 
ten  with  gastric  symptoms  has  a  gastric  lesion,  is  w^orth  remem- 
bering. The  beginner  is  likely  to  be  disappointed  by  the  multi- 
tude of  cases  in  which  he  is  unable  to  find  any  roentgenologic 
evidence  of  a  gastro-intestinal  lesion,  and  will  often  feel  that  he 
is  at  fault.  But  besides  a  percentage  of  patients  with  such 
lesions  which  no  one  is  as  yet  able  to  discover,  there  will  be  a 
much  larger  number  of  patients  whose  symptoms  are  produced 
by  conditions  outside  the  digestive  tract.  Extrinsic  conditions 
giving  rise  to  abdominal  symptoms  are  sometimes  discoverable 
during  an  examination  of  the  digestive  tract.  The  observer 
should  keep  in  mind  the  possibility  of  aneurysm,  pleural,  pul- 
monary, mediastinal  and  cardiac  disease,  diaphragmatic  hernia 
and  eventration,  subdiaphragmatic  abscess,  gall-stones,  renal, 


36  INTERPRETATION 

ureteral  and  vesical  stones,  enlargements  and  tumors  of  the 
kidney,  spleen,  liver  and  pancreas.  He  should  watch,  at  least 
casually,  for  vertebral  disease,  for  fractures  and  deformities, 
in  short,  for  every  abnormality,  and  report  it  whether  it  may  or 
may  not  have  any  relation  to  the  patient's  complaints.  To  be 
sure,  gall-stones  and  stones  in  the  urinary  tract  are  likely 
to  be  overshadowed  by  the  barium  and  discovery  of  them  will 
be  only  fortuitous,  but  if  their  presence  is  suspected  they  should 
be  looked  for  at  a  separate  examination. 

The  hazard  attending  diagnosis  based  exclusively  on  plate 
findings,  especially  when  the  plates  are  few  in  number,  deserves 
particular  stress.  Plates  show  but  a  single  phase  and  a  single 
angle  of  view.  Artefacts  which  may  be  produced  in  countless 
ways,  the  appearances  which  are  physiologic  and  the  signs  which 
are  pathologic  cannot  be  distinguished  from  each  other  with  any 
degreee  of  certainty  if  only  one  or  two  plates  are  made.  Yet, 
when  used  as  a  complement  to  the  screen,  the  plate  may  give 
substantial  aid,  and  it  should  be  employed  in  that  manner  only. 

How  shall  the  examiner  report  his  findings?  How  far 
shall  he  go  in  translating  them  into  terms  of  diagnosis?  This 
depends  on  his  relations  to  the  clinician,  the  acquaintance  which 
each  has  with  the  other's  province,  and  whether  the  work  is 
done  in  an  organized  institution  or  independently.  An  ultra- 
conservative  method  would  be  simply  to  report  the  bare  facts 
of  the  observation — a  shadow  here,  a  filling-defect  there,  a 
residue,  or  whatever  is  seen — and  leave  all  diagnostic  interpre- 
tation to  the  clinician.  To  be  wholly  satisfactory  this  would 
necessitate  an  extent  of  organization  which  has  not  yet  been 
reached,  and  few  clinicians  understand  the  precise  significance 
of  roentgenologic  indications.  For  this  reason  verbose  reports 
of  all  the  roentgen  phenomena  observed  in  a  given  case  are  worse 
than  useless  because  they  may  mislead  the  clinician,  and  a 
simple  statement  of  the  conclusions  formed  would  be  far  better. 

Another  way  would  be  for  the  roentgen  examiner  to  restrict 
his  diagnoses  to  those  cases  in  which  the  roentgen  signs  alone 
are  pathognomonic,  or  practically  so,  such  as  the  niche  of  gastric 


INTERPEETATION  37 

ulcer  or  the  filling-defect  of  advanced  carcinoma.  Certainly  he 
can  perform  valuable  service  in  this  manner,  but  what  of  the 
cases  in  which  the  roentgen  signs,  though  definitely  abnormal, 
are  not  definitely  diagnostic,  and  yet  may  corroborate  a  clinical 
picture?  As  a  concrete  illustration  may  be  cited  the  occurrence 
of  a  six-hour  gastric  residue  with  apparent  cutting-off  of  the 
prepyloric  region,  phenomena  w^hich  are  definitely  abnormal  but 
which  are  alone  not  sufficient  to  maintain  a  diagnosis  either  of 
cancer  or  ulcer.  The  roentgenologist  from  his  observations 
alone  can  say  only  that  a  pathologic  condition  exists.  Yet 
these  signs  when  combined  with  the  clinical  facts,  may  point 
rather  directly  to  the  nature  of  the  lesion. 

Extreme  limitations  of  diagnostic  latitude  are  not  truly  con- 
servative, but  are  reactionary.  They  would  seem  to  rest  on 
the  assumption  that  a  diagnosis  is  a  statement  of  fact,  not  an 
expression  of  opinion.  Yet  every  diagnosis  implies  the  exercise 
of  opinion  and  the  rendition  of  judgment,  and  even  the  patholo- 
gist, who  has  the  last  word  in  this  respect,  is  not  infallible. 

It  is  less  important  that  we  be  solicitous  regarding  artificial 
rules  which  we  may  impose  on  ourselves — as  though  a  game 
were  being  played — than  that  we  remember  the  rights  of  the 
patient.  It  is  his  just  due  that  all  features  of  his  condition 
shall  be  properly  weighed,  not  only  separately  but  also  in  their 
relations  to  each  other  and  as  a  whole.  Many  roentgen  mani- 
festations are  as  yet  intelligible  only  in  the  light  of  clinical  and 
other  facts. 

It  follows,  then,  that  somewhere  and  somehow  the  roentgeno- 
logic findings  should  be  correlated  with  the  clinical  as  well  as 
all  other  data.     How  shall  this  be  done? 

1.  It  may  be  done  by  the  clinician.  This  implies  a  broad 
knowledge  on  his  part  of  roentgen  diagnostics,  which  can  be 
acquired  only  after  years  of  experience.  Reduced  to  practical 
terms  it  means  that  it  would  be  better  for  the  clinician  to  make 
his  own  roentgenologic  examinations.  Possibly  th  s  is  the 
ultimate  solution. 

2.    The    clinician    and    the    roentgenologist    may    make    a 


38  INTERPRETATION 

joint  examination,  or  go  over  their  respective  findings  at  a 
personal  conference.  Active  co5peration  would  certainly  be 
preferable  to  the  customary  passive  combination  of  their  work. 
3.  The  roentgenologist  himself  may  correlate  his  findings 
with  the  clinical  and  other  data.  Under  present  conditions 
this  is  perhaps  the  most  practical  and  efficient  method.  As  a 
medical  man  he  should  have  little  difficulty  in  refreshing  his 
knowledge  of  symptoms,  laboratory  reports,  and,  at  least  gross, 
physical  signs.  By  so  doing,  his  work  will  rest  on  broader 
foundations,  and  not  only  will  his  interpretations  be  tempered 
by  the  clinical  data,  but  he  will  also  acquire  a  more  exact  sense 
of  purely  clinical  values. 

The  clinical  data  may  be  used: 

1.  In  combination  with  the  roentgen  observations  to  form 
a  general  complex  on  which  the  diagnosis  is  based. 

2.  As  an  index  of  the  possibilities  and  probabilities  in  the 
case  at  hand  and  thus  direct  the  examiner's  particular  atteiition 
to  them. 

3.  To  prevent  too  hasty  judgment,  as  in  those  cases  in  which 
the  roentgen  signs  do  not  harmonize  with  the  clinical  facts, 
and  in  which  a  more  careful  review  of  these  signs  or  a  reexami- 
nation may  show  them  to  have  been  mistaken. 

[Fear  has  been  expressed  in  some  quarters  that  clinical  data 
may  unduly  prejudice  the  roentgenologist  and  give  bias  to  his 
verdicts.  This  could  occur  only  on  condition  that  his  experi- 
ence has  not  been  sufficient  to  teach  him  the  relative  value  of 
signs,  either  roentgenologic  or  clinical. 

To  sum  up,  the  essentials  for  satisfactory  roentgen  diagno- 
sis are  faithfulness  to  an  orderly  routine,  careful  observation, 
reexamination  in  doubtful  cases,  cautious  and  correlated  inter- 
pretation, and  last,  but  not  least,  a  willingness  to  admit  when- 
ever it  is  true,  that  the  findings  are  inconclusive. 


CHAPTER  IV 

THE  ESOPHAGUS 

Technic. — While  in  most  cases  no  special  preparation  of  the 
patient  is  necessary  for  an  examination  of  the  esophagus,  there 
are  cases  of  obstruction  in  which  retained  food  or  secretion  may 
interfere  with  the  examination  or  impair  the  accuracy  of  its 


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Fig,  4. 


-Cross-section  diagram  showing  position  of  the  esophagus  relative  to  other 
organs  in  the  oblique  view. 


results.  Whenever  such  conditions  are  suspected  it  is  advisable 
to  have  the  gullet  cleared  out  either  by  the  voluntary  efforts 
of  the  patient  or  by  tubing  and  lavage. 

Standing  with  his  back  to  the  tube  and  with  the  screen 
against  his  chest,  the  patient  should  first  be  given  a  general 
survey  in  the  anterior  position.  With  the  diaphragm  widely 
extended,    the    entire    chest    should    be    inspected,    attention 

39 


40 


THE    ESOPHAGUS 


being  given  to  the  supraclavicular  regions,  the  lungs  during  forced 
respiration,  the  excursions  of  the  diaphragm,  and  the  size  and 
position  of  the  heart  and  aorta. 


Fig.  5. 


-Screen    examination    of    the    esophagus.     Patient   in   right    anterior   oblique 

position. 


^The  patient  is  then  turned  to  an  angle  of  about  forty-five 
degrees  so  that  his  left  scapula  is  directed  toward  the  tube, 
while  the  screen  hangs  over  his  right  chest.  In  this  position, 
the  right  anterior  oblique,  the  rays  pass  through  the  patient 
obliquely,  as  shown  in  the  cross-section  diagram  (Fig.  4),  and 


TECHNIC 


41 


the  photograph  (Fig.  5).  The  exact  angle  desired  can  rarely 
be  obtained  beforehand,  but,  looking  on  the  screen,  the  observer 
can  rotate  the  patient  slightly  in  either  direction  until  the 
greatest  space  is  attained  between  the  shadow  of  the  vertebral 
column  behind  and  that  of  the  heart  and  aorta  in  front.  The 
horizontal  leaves  of  the  diaphragm  are  extended  to  their  limit, 
while  the  vertical  leaves  are  approximated  until  only  the  esoph- 
ageal region  is  in  the  visible  field.     Screens  of  average  size 


:.>r-^    I- 


- TD'- 

.^ i^-'.. 

q; 


•> 


'(■■■' 


1     ■"■■ 

-^:. 

,1 
T    , 

■4.  ■■■■■ 

■■  -Q 

■-A- 

a:\ 

■v^.: 


Fig.    6- — Diagrammatic   view,    right   anterior    oblique   position. 

space. 


A,  A,  retrocardiac 


will  not  accommodate  the  whole  extent  of  the  esophagus,  and 
hence  require  raising  and  lowering  to  cover  the  entire  course. 
Besides,  for  clear  vision  and  to  avoid  distortion,  it  is  better  to 
have  a  small  field  with  the  tube  and  screen  in  the  plane  of  any 
point  which  is  to  be  closely  scrutinized. 

After  the  patient  is  satisfactorily  posed  he  is  given  a  barium- 
acacia  mixture,  a  teaspoonful  at  a  time.  This  is  prepared  by 
mixing  four  parts  of  barium  sulphate  with  one  part  of  fresh 
mucilage  of  acacia,  as  described  by  Hirsch,^  who,  however, 
prefers  bismuth  instead  of  barium.     When  first  mixed  it  is 


42 


THE    ESOPHAGUS 


rather  dry  and  granular,  but  by  continued  stirring  becomes 
smooth  and  homogenous.  A  total  of  2  to  4  spoonfuls  is  all 
that  is  necessary.  The  resulting  mass  is  exceedingly  viscid. 
It  descends  the  esophagus  slowly  and  tends  to  coat  its  walls 


.'Fig.  7.— Patient  in  right  anterior  oblique  position  for  roentgenography  of  the 

esophagus. 

throughout.  Each  bolus  is  followed  in  its  progress  down- 
ward. For  additional  observation  the  patient  drinks  a  cupful 
of  bariumized  gruel  (2  ounces  of  barium  sulphate  in  3  or  4 
ounces  of  a  thin  gruel  of  any  breakfast  cereal).     This  can  be 


TECHNIC 


43 


swallowed  in  larger  quantities  than  the  acacia  mixture  and 
shows  the  distensibility  of  the  esophagus  somewhat  better. 
If  the  esophagus  is  markedly  dilated  above  an  obstruction, 
greater  amounts  of  bariumized  gruel  or  corn-starch-pap  are 
given  to  show  the  extent  of  dilatation. 


/ 


Fig.  8. — ^Position  of  patient  for  roentgenography  of  the  epicardia.     A  small  cone  should 
be  used  to  secure  good  definition. 

In  the  right  anterior  oblique  position,  the  esophagus,  with 
the  exception  only  of  its  short  subdiaphragmatic  portion,  can 
be   studied   to   best    advantage.     Particular   attention  should 


44  THE    ESOPHAGUS 

be  paid  to  the  retro-cardiac  space,  the  clear  area  lying  between 
the  spine  and  the  heart  and  large  vessels.  Encroachment  upon 
this  space  should  suggest  the  possibility  of  an  aneurysm  or 
mediastinal  tumor.  The  drawing  illustrates  (Fig.  6)  the  nor- 
mal relations. 

The  anterior  position,  the  patient  facing  the  observer 
squarely  (or  at  a  very  slight  angle)  is  desirable  for  inspection  of 
the  subdiaphragmatic  portion  of  the  esophagus  and  also  for 
determining  the  position  of  lateral  diverticula. 

In  making  roentgenograms  it  is  better  to  select  that  position 
which  during  the  screen  examination  showed  the  conditions  to 
best  advantage.  For  the  oblique  view  the  plate,  taking  the 
place  of  the  screen,  should  have  the  same  degree  of  obliquity 
(Fig.  7).  Plating  in  the  anteroposterior  view  (Fig.  8),  with 
the  patient's  back  against  the  cassette,  is  advantageous  for  show- 
ing lesions  of  the  epicardia.  Plates  11  by  14  inches,  or  14  by 
17  inches,  should  be  used  with  the  intensifying  screen,  and  the 
tube  at  a  distance  of  20  to  30  inches.  By  using  a  small  cone 
and  small  plate,  lesions  which  have  been  located  exactly  can 
be  shown  with  better  definition.  Many  prefer  to  make  plates 
with  the  patient  recumbent,  and  we  often  make  them  in  this  way. 

Variations  of  technic,  both  in  screening  and  plating,  can  be 
improvised  to  suit  the  circumstances  of  the  case.  The  left 
posterior  oblique  position,  which  is  the  reverse  of  the  right 
anterior  oblique,  and  the  posterior  position,  the  patient 
facing  the  tube,  are  occasionally  employed.  Lateral  positions, 
either  right  or  left,  are  sometimes  satisfactory  if  the  patient  be 
not  too  broad-chested. 

Different  media  may  be  used,  such  as  fermented  milk,  bread- 
and-milk,  or  any  sort  of  porridge.  The  use  of  barium  or  bis- 
muth in  capsules  for  determining  obstruction  is  not  advised. 
Capsules,  whether  large  or  small,  behave  as  foreign  bodies  in 
the  esophagus,  are  swallowed  wdth  difficulty  as  a  rule,  and  may 
lead  to  an  erroneous  diagnosis  of  obstruction. 

In  1912  Myer  and  Carman-  demonstrated  the  persistence 
of  dilatation  years  after  symptomatic    cure    of    cardiospasm. 


TECHNIC  45 

They  employed  for  the  demonstration  a  thin  rubber  bag  tied 
over  the  end  of  a  rubber  tube.  The  bag-tipped  tube  was 
passed  down  to  the  cardia  and  then  filled  with  a  bismuth 
mixture  injected  through  the  tube  by  a  syringe.  By  this  means 
the  dilatation  could  still  be  observed,  both  on  screen  and 
plate,  though  obstruction  had  ceased. 

Later,  Bassler^  made  use  of  the  bag-tipped  tube,  which  was 
passed  into  the  stomach,  filled  with  water,  and  pulled  up  into 
the  cardia,  thus  blocking  it.  The  esophagus  above  it  and  outside 
the  tube  was  filled  with  a  bismuth  suspension  in  order  to  de- 
termine the  presence  of  irregularities  and  lesions  in  esophagi 
which  were  not  sufficiently  stenosed  to  show  signs  with  the 
ordinary  technic.  The  method  occasioned  considerable  dis- 
comfort to  the  patient  and  caused  retching  and  regurgitation. 
The  bulkiness  of  the  bag  and  tube  made  it  difficult  to  pass 
through  small  strictures  and,  on  the  whole,  the  procedure  was 
unsatisfactory. 

Crump^  employs  sausage-skins,  as  cleaned  and  prepared  for 
packing  houses,  which  he  keeps  in  a  solution  of  1  per  cent, 
liquor  formaldehyd  and  10  per  cent,  glycerin.  The  distal  end 
is  tied  with  a  piece  of  silk  floss  so  as  to  make  a  bag.  The 
proximal  end  is  slipped  over  a  rubber  tube  and  tied.  The 
empty  bag  is  practically  only  a  string,  and,  with  the  aid  of  a 
little  water,  is  swallowed  by  the  patient,  after  cocainizing  the 
pharynx  if  necessary.  It  is  then  ffiled  through  the  tube  from 
an  irrigator  with  a  bismuth  emulsion  and  the  roentgenographic 
examination  made.  The  skins  are  easily  obtained  and  it  is 
claimed  that  by  this  method  the  exact  extent  of  involvement 
can  be  seen,  and  early  as  well  as  late  lesions  can  be  outlined. 
It  is  stated  also  that  it  is  especially  applicable  to  non-stenotic 
conditions. 

In  many  instances  it  is  advisable  to  supplement  the  esoph- 
ageal examination  with  an  examination  of  the  stomach  to 
elucidate  the  symptoms  complained  of.  In  this  event  the 
patient  should  have  the  usual  preliminary  preparation  for 
gastric  examination  and  should  be  examined  in  the  horizontal 


46  THE   ESOPHAGUS 

position,  either  supine  or  prone,  or  even  in  the  Trendelenburg 
position,  for  lesions  high  in  the  cardiac  portion  of  the  stomach. 

The  roentgenologist  must  expect  frequent  negative  results, 
even  in  patients  whose  history  is  fairly  emphatic.  Some  of 
these  are  perhaps  merely  neurotic;  in  others  the  trouble  is 
spasmodic  and  intermittent,  and  in  these  an  examination  is 
usually  negative  unless  made  during  an  attack.  Repeated 
examinations  are  often  necessary  to  show  intermittent  stenotic 
conditions  and  to  differentiate  them  from  organic  and 
permanent  obstructions. 

Interpretation  of  esophageal  findings,  unless  they  are  extra- 
ordinarily typical,  should  be  cautious.  If  the  examiner  is 
not  thoroughly  acquainted  with  the  clinical  facts  in  the  case, 
he  had  better  report  simply  what  he  sees  without  atlbempting 
to  translate  his  observations  into  a  diagnosis.  He  may  say, 
for  example,  that  obstruction  of  a  certain  degree  was  noted, 
with  or  without  irregularity  of  contour  at  a  certain  point,  or 
report  whether  or  not  there  is  evidence  of  a  lesion  outside  the 
esophagus.  The  information  may  be  associated  by  the  clinician 
with  his  own  data  and  a  conclusion  formed.  This  caution  is 
necessary  because  of  the  frequent  roentgenologic  similarity  of 
various  esophageal  lesions. 

ANATOMICAL  MEMORANDA 

Directly  after  its  beginning  (the  introitus)  at  the  cricoid 
cartilage,  the  esophagus  swerves  to  the  left  so  that  it  projects 
slightly  beyond  the  left  border  of  the  trachea.  Above  the  bifur- 
cation of  the  trachea  it  is  pushed  to  the  right  and  somewhat 
posteriorly  by  the  aorta.  Passing  behind  the  beginning  of  the 
left  bronchus  it  descends  with  the  aorta  which  it  half  entwines 
so  as  to  lie  in  front  of  the  aorta  just  above  the  diaphragm. 
Running  obliquely  to  the  left,  it  passes  through  the  diaphragm 
at  the  hiatus  esophagi,  which  is  about  at  the  level  of  the  tenth 
dorsal  vertebra,  and  thence  continues  very  obliquely  to  the 
left  into  the  stomach.  The  average  total  length  of  the  esophagus 
is  about  25  cm.,  of  which  3  to  5  cm.,  the  epicardia,  lies  below  the 


THE    NORMAL   ESOPHAGUS  47 

diaphragm.  The  caliber  is  somewhat  irregular,  one  investi- 
gator having  noted  thirteen  shght  constrictions  in  its  course. 
The  anatomical  points  of  narrowing  that  are  of  chief  importance 
are  as  follows: 

1.  At  the  introitus. 

2.  At  the  aortic  arch. 

3.  At  the  crossing  of  the  left  bronchus. 

4.  At  the  hiatus  esophagi. 

5.  At  the  cardiac  opening. 

The  entire  epicardia  is  distinctly  narrower  than  the  rest 
of  the  esophagus. 

THE  NORMAL  ESOPHAGUS  AS  SHOWN  BY  THE  ROENTGEN-RAY 

Movements. — The  act  of  swallowing,  as  seen  with  the  x- 
ray,  may  be  divided  into  two  phases,  a  pharyngeal  and  an 
esophageal.  In  the  first  phase  the  bolus  is  passed  back  into 
the  pharynx  by  the  tongue,  the  intrapharyngeal  pressure  is 
increased  by  contraction  of  the  muscles  of  the  pharynx  until 
the  introitus  relaxes,  and  the  food  is  forced  into  the  esophagus. 
In  the  second  phase  the  bolus  passes  rapidly  down  the  esoph- 
agus to  the  cardia,  is  held  there  momentarily,  and  then  enters 
the  stomach.  The  rate  and  manner  of  descent  vary  consider- 
ably with  the  consistence  of  the  bolus,  its  size,  form,  taste  and 
temperature.  The  time  required  to  complete  the  act  of  deglu- 
tition varies  all  the  way  from  two  seconds  to  eight  or  ten.  Fluids 
descend  quickly,  while  solids  travel  slowest.  Thin  fluids  go 
down  in  an  almost  continuous  stream;  thick  fluids  and  semi- 
solids are  broken  up  into  detached  finger-sized  masses.  The 
latter,  as  a  rule,  hesitate  at  the  narrowings  mentioned,  espe- 
cially at  the  introitus,  the  crossing  of  the  left  bronchus  and  the 
cardia.  According  to  some  observers,  the  delay  at  the  cardia 
consumes  about  half  of  the  total  time  required  in  a  single  act  of 
swallowing. 

Peristalsis. — The  fluidity  of  the  media  customarily  em- 
ployed, the  rapidity  of  the  act  of  deglutition  and  the  numerous 


48  THE   ESOPHAGUS 

anatomic  irregularities  of  the  esophagus  combine  to  make  the 
detection  of  peristalsis  difficult.  The  propulsive  effect  of 
pharyngeal  constriction  at  the  commencement  of  deglutition 
and  the  influence  of  gravity,  especially  as  shown  by  the  behavior 
of  fluids  in  the  esophagus  of  a  standing  patient,  add  to  the  com- 
plexity of  this  function  and  the  difficulty  of  its  analysis.  How- 
ever, esophageal  peristalsis  is  frequently  observed  under  both 
normal  and  abnormal  conditions.  According  to  Holzknecht,^ 
the  peristaltic  wave  occurs  as  a  constriction  ring  about  1  cm. 
broad,  driving  the  ingesta  before  it.  Its  speed  has  been  stated 
as  1  inch  per  second.  Like  that  of  the  stomach,  peristalsis 
of  the  esophagus  is  subject  to  numerous  normal  and  abnormal 
variations  in  force  and  frequency,  but  aside  from  the  exaggera- 
tion of  peristaltic  activity  seen  in  stenotic  conditions,  cardio- 
spasm, for  example,  and  reverse  peristalsis  as  noted  in  obstruct- 
ive cases,  these  variations  are  seldom  seen  or  regarded. 

THE  PATHOLOGIC  ESOPHAGUS  AS  SEEN  WITH  THE  ROENTGEN-RAY 

Displacem,ent. — Displacement  of  the  esophagus  in  its  course 
may  occur  as  a  result  of  aneurysm,  pleural,  pulmonary  or  medi- 
astinal inflammations,  mediastinal  tumor,  substernal  thyroid, 
vertebral  diseases  or  deformity,  or  cardiac  enlargement.  Dis- 
placement by  an  intrinsic  lesion  is  relatively  rare,  although  a 
filled  diverticular  sac  may  push  the  esophagus  aside. 

Deformity  of  Contour. — Irregularities  of  contour  may  be 
produced  either  by  extrinsic  or  intrinsic  conditions.  Localized 
filling  defects  may  result  from  the  pressure  of  an  aneurysm  or 
mediastinal  tumor.  Retained  food-bits  in  obstructive  cases 
may  produce  irregularities  resembling  those  of  a  new  growth. 
The  principal  intrinsic  lesions  which  alter  the  esophageal  out- 
line are  carcinoma,  benign  stricture,  cardiospasm  and  diverti- 
culum. Unless  there  be  rather  marked  stenosis,  minor  inden- 
tations of  the  esophageal  wall  wdll  hardly  be  visualized  during 
the  brief  transit  of  opaque  media.  In  any  event,  the  numerous 
slight  normal  irregularities  must  be  borne  in  mind.     The  deform- 


OBSTRUCTION  49 

ity  of  contour  produced  by  a  diverticulum,  showing  as  a  pouch- 
like addition  to  the  esophageal  lumen,  can  hardly  escape  notice. 

Obstruction. — Stenosis  is  evidenced  by  retardation  of  the 
opaque  medium  in  its  passage  through  the  esophagus,  by  visible 
narrowing  of  the  lumen,  sometimes  by  evident  dilatation  above 
the  strictured  area  and  occasionally  by  exaggerated  or  reverse 
peristalsis.  The  degree  of  retardation  will  depend  somewhat 
upon  the  fluidity  of  the  medium  employed  as  well  as  the  tight- 
ness of  the  constriction.  Opaque  capsules  should  not  be  used, 
for  reasons  previously  mentioned.  In  seeking  for  evidences  of 
obstruction,  regard  must  be  had  for  the  slight  delay  often  noted 
normally  at  the  introitus,  the  left  bronchial  crossing  and  the 
cardia  and  for  physiologic  factors  affecting  the  rapidity  of  de- 
scent. With  high-seated  stenosis,  regurgitation  of  the  medium 
may  hinder  visualization. 

The  commonest  extra-esophageal  causes  of  obstruction  are 
aneurysm  and  mediastinal  inflammation  or  tumor.  Other 
extrinsic  conditions  sometimes  causing  compression  are  sub- 
sternal goiter,  vertebral  lesions,  aortic  dilatation,  tuberculous 
glands  and  enlargement  of  the  heart.  Compression  stenoses 
almost  always  affect  the  mid-portion  of  the  esophagus.  When 
viewed  in  the  oblique  position  the  encroachment  of  an  aneurysm 
or  aortic  dilatation  upon  the  retrocardiac  space  and  its  expansile 
pulsation  make  the  diagnosis  possible.  Vertebral  deformity, 
substernal  goiter  and  cardiac  enlargement  show  roentgenologic- 
ally.  The  roentgenologic  evidences  of  mediastinitis,  mediastinal 
tumor  and  tuberculous  glands  are  less  obvious,  but  the  increased 
density  without  expansile  pulsation  is  suggestive.  Compression 
stenoses  are  apt  to  be  associated  with  displacement  of  the  esoph- 
agus, and  this  fact  is  important  in  differentiating  them  from 
lesions  of  the  esophagus  itself.  Obstruction  due  to  outside 
pressure,  as  by  an  aneurysm,  is  less  marked  than  obstruction 
from  an  intrinsic  lesion. 

Some  of  the  intrinsic  causes  of  obstruction  are  cardiospasm, 
carcinoma,  diverticulum,  benign  cicatricial  strictures,  foreign 
bodies,  polypi  and  reflex  spasm.     To  these  might  be  added  the 


50  THE   ESOPHAGUS 

rare  cases  of  abscess  (as  from  a  foreign  body),  syphilis,  tuber- 
culosis and  actinomycosis.  A  large  diverticular  sac  when 
filled  may  exert  sufficient  pressure  to  obstruct  the  esophagus 
considerably. 

It  is  noteworthy  that  the  patient's  dysphagia  is  often  out 
of  proportion  to  the  roentgenologic  signs  of  obstruction.  With 
fluids  or  even  with  porridge  there  is  often  seen  onl}^  shght  delay 
or  none  at  all.  Barclay^  sometimes  gives  such  patients  dry 
bread  crumbs  or  crusts  in  order  to  excite  spasm,  and  then  follows 
with  the  barium  mixture  to  show  its  seat. 

Dilatation. — More  or  less  dilatation  is  a  common  sequel  of 
an  obstruction.  The  most  extreme  dilatation  is  seen  in  cases 
of  cardiospasm,  where  the  esophagus  may  attain  a  breadth  of 
three  fingers  or  more.  Dilatation  above  carcinomatous  steno- 
sis is  commonly  less  marked  than  above  benign  obstruction. 
A  small,  contracted,  carcinomatous,  syphiUtic  or  high  hour-glass 
stomach  may  cause  dilatation  of  the  lower  esophagus  by  the 
backing  up  of  the  gastric  contents. 

The  dilated  esophagus  consequent  upon  obstruction,  espe- 
cially that  due  to  cardiospasm,  often  contains  a  quantity  of 
fluid  secretion  through  which  the  barium  falls  slowly,  often  in  a 
winding  manner,  at  first  suggesting  the  irregular  lumen  of  an 
esophageal  carcinoma.  Continued  filling  will  indicate  the 
condition.  In  such  cases,  evacuation  with  the  stomach-tube 
and  reexamination  is  advisable. 

CARDIOSPASM 

The  chief  roentgenologic  characteristics  of  typical  cardio- 
spasm are  the  blunt  or  regularly  conical  obstruction  at  or  near 
the  cardia,  and  the  secondary  dilatation  of  the  esophagus  above 
it.  The  smooth,  symmetrical  termination  of  the  shadow,  usu- 
ally at  the  hiatus  esophagi,  less  frequently  at  the  cardia,  is 
rarely  seen  in  any  other  condition.  The  dilatation  is  often 
extreme,  involving  almost  the  entire  esophagus.  It  may  thus 
attain  a  capacity  of  a  pint,  or  even  more.     In  some  cases,  the 


CARDIOSPASM  51 

dilated,  sac-like  esophagus  may  contain  much  fluid  through 
which  the  opaque  meal  falls  in  blobs.  The  dilated  fluid-filled 
esophagus  is  occasionally  visible  at  the  side  of  the  spine,  on  the 
screen  before  giving  the  barium.  The  upper  esophageal  con- 
tour is  fairly  regular,  but  is  sometimes  indented  here  and  there 
by  sharp,  moving  contraction-waves  or,  occasionally,  by  a 
stationary  spasmodic  constriction.  Because  of  the  dilatation, 
peristalsis  is  not  effective  in  its  effort  to  propel  the  esophageal 
contents  into  the  stomach,  and  the  patient  depends  upon 
increasing  the  intra-esophageal  pressure  by  adding  to  its  con- 
tents and  by  energetic  contraction  of  the  pharynx.  Thus  by 
drinking  a  glass  of  water  after  taking  food,  he  is  often  able  to 
overcome  the  obstruction  at  the  cardia  and  drive  the  food  into 
the  stomach.  In  cases  of  long  standing  the  esophagus  may  be 
more  or  less  elongated  and  somewhat  kinked,  or  S-shaped. 
Antiperistalsis  has  been  noted  and  is  a  natural  sequence  of 
obstruction  anywhere  in  the  digestive  tube. 

Cardiospasm  is  to  be  differentiated  chiefly  from  carcinoma 
and  from  benign  organic  stricture.  Carcinoma  of  the  lower 
esophagus  rarely  produces  stenosis  limited  to  the  hiatus  esoph- 
agi, but  nearly  always  extends  above  the  diaphragmatic 
opening  and,  as  a  rule,  the  lower  end  of  the  barium  shadow 
tails  out  irregularly.  Post-traumatic  strictures  sometimes  occur 
in  the  lower  esophagus,  but  here  again  one  may  expect  irregu- 
larity instead  of  the  symmetrical  cone  of  cardiospasm.  However, 
warning  must  be  given  that  irregularity  does  not  invariably 
signify  organic  obstruction,  nor  does  smooth  regularity  invariably 
indicate  cardiospasm.  Exceptionally  a  cardiospasm  may  show 
a  slightly  devious  tailing  out,  and  exceptionally  an  organic 
stricture  may  not  give  rise  to  an  irregular  shadow. 

Case  114,572,  female,  aged  27.  During  the  past  four  years  this 
patient  has  had  intermittent  attacks  of  discomfort  behind  the  ster- 
num while  eating.  The  food  seemed  to  lodge  before  entering  the 
stomach.  Upon  drinking  hot  water  the  food  seemed  to  pass  suddenly 
into  the  stomach.  Unless  she  remained  quiet  for  a  time  after  eating, 
the  meal  came  up  just  as  swallowed  without  nausea.     During  the  past 


52 


THE    ESOPHAGUS 


two  years  she  seldom  took  a  meal  without  this  trouble.  She  drinks 
large  quantities  of  liquid  with  her  food.  Cold  water  causes  distress 
and  is  regurgitated  immediately  after  swallowing.  The  patient  is 
constantly  losing  weight. 

Roentgenoscopy  and  the  roentgenogram  (Fig.  9)  show  marked 
obstruction  at  the  cardia,  where  the  esophageal  lumen  has  a  smooth, 
conical  termination.  Above  the  obstruction  the  esophagus  is  con- 
siderably dilated. 


Fig.  9. — Cardiospasm,     (a)   Constriction.     Note  dilatation  above. 


Dilatation  with  the  hydrostatic  bag  effected  a  clinical  cure. 

Case  111,736,  female,  aged  30.  Fourteen  years  ago  she  began  to 
have  occasional,  sudden,  sharp  pain  just  behind  the  center  of  the 
sternum,  intense  for  a  few  moments,  with  no  food  relation  and  relieved 
by  belching.  Two  years  ago  she  had  a  severe  attack  of  vomiting  and 
soon  afterward  began  to  have  a  choking  sensation  on  swallowing 
solid  foods.  She  frequently  resorted  to  drinking  water  to  force  food 
down  and  became  unable  to  eat  a  meal  without  taking  considerable 
liquid.  Later  she  began  to  vomit  while  at  meals,  and  often  was 
obliged  to  leave  the  table  though  hungry.  There  never  was  marked 
nausea.  One  year  ago  she  began  having  her  stomach  washed  out,  and 
learned  to  use  the  tube  herself,  employing  it  once  a  week  for  the  past 
eight  months.     She  discovered  on  one  occasion  that  the  tube  could 


CARDIOSPASM 


53 


Fig.    lOx. — Cardiospasm.     Spasmodic     constriction,  a.       Filling-defect    due    to    food 

remnants,  h. 


Fig.  IQy. — Cardiospasm;  same  case  shown  in  Fig.  lOx,  after  washing  out  esophagus. 
Constriction  at  a.     Note  absence  of  filling-defect. 


54  THE   ESOPHAGUS 

not  be  passed  into  the  stomach  and  called  a  physician  who  made  a 
diagnosis  of  diverticulum.  At  present  she  vomits  two  or  three  times 
at  each  meal,  and  often  cannot  get  sufficient  food  into  her  stomach  to 
satisfy  her  hunger.  No  pain  is  experienced.  Appetite  good.  Weight 
and  strength  slightly  below  normal. 

Two  roentgenograms  are  shown  (Figs.  10a;  and  lOy).  Figure  10a:, 
made  at  the  first  examination,  shows  obstruction  at  the  cardia  with 
an  irregularity  of  its  lower  left  border  resembling  the  filling-defect  of 
a  neoplasm.  In  order  to  exclude  food  remnants  as  the  cause  of  this 
appearance,  the  patient's  esophagus  was  washed  out  with  the  tube  and 
a  second  roentgenogram  made  (Fig.  lOy).     In  this  the  filling-defect 


Fig.   11. — Cardiospasm.     Hiatus  esophagi,  a.     Constriction  at  cardia,  6.     Some  dilata- 
tion of  epicardia,  a  to  b.     Marked  dilatation  above  a.     Direct  anterior  view. 

has  disappeared.  Doubtless,  therefore,  it  was  due  as  was  suspected 
to  food-bits.  Both  roentgenograms  show  the  characteristic  obstruc- 
tion at  the  cardia  with  diffuse  dilatation  of  the  esophagus  above. 

Forcible  dilatation  was  followed  by  clinical  cm-e. 

Case  105,770,  male,  aged  49.  When  a  child  the  patient's  esophagus 
was  burned  with  hot  mush,  after  which  he  spat  up  bloody  mucus  for  a 
time.  His  chief  complaint  was  difficulty  in  swallowing.  He  has  had 
his  present  trouble  since  the  age  of  14  years;  first  noticed  that  in  eating 
an  apple,  he  had  to  drink  water  to  force  it  down.     This  is  true  also  with 


CAEDIOSPASM 


55 


other  solid  foods.  The  patient  states  that  he  can  feel  the  lower  end 
of  the  esophagus  loosen  up  and  let  food  go  through.  Usually  water 
alone  will  not  go  through  and  comes  up  sooner  or  later.  He  often 
awakens  at  night  and  has  to  rid  himself  of  collected  saliva.  On  a  few 
occasions  he  has  had  to  empty  his  esophagus  of  food  after  eating 
too  heartily. 

The  roentgenogram  (Fig.  11)  shows  marked  obstruction  at  the 
cardia.  The  subdiaphragmatic  portion  of  the  esophagus  is  dilated, 
but  above  the  hiatus  the  esophageal  dilatation  is  extreme  and  ex- 
tends to  the  upper  border  of  the  sterum,  the  esophagus  having  a' di- 
ameter of  approximately  3}4  inches.     The  cardiospasm'was  relieved 


Fig.   12. — Cardiospasm.     Spasmodic  constriction  at  a. 


by  forcible  dilatation  with  the  hydrostatic  bag.  It  is  of  interest  to 
note,  as  a  possible  etiologic  factor,  that  for  some  years  the  patient  had 
also  had  symptoms  suggestive  of  duodenal  ulcer.  About  two  years 
after  the  esophageal  stretching,  the  presence  of  a  duodenal  ulcer  was 
confirmed  by  roentgen  examination,  and  verified  at  operation. 

Case  136,926,  male,  aged  37.  In  a  letter  this  patient  related  a 
typical  history  of  cardiospasm,  as  follows:  "I  have  had  all  manner 
of  treatment  but  it  seems  to  do  no  good.  Twelve  years  ago  I  had  a 
bougie  passed  down  my  throat  and  into  my  stomach  once  a  day  for 
thirty  days.     Then  I  took  all  kinds  of  vibration  and  electrical  treat- 


56 


THE   ESOPHAGUS 


Fig.  13. 


Fig.  14. 


Fig.  15. 


Fig.  16. 


Fig.  17.  Fig.  18. 

Figs.  13,  14,  15,  16,  17  and  IS. — Roentgenograms  illustrating  cardiospasm. 


CARCINOMA  57 

merits  without  benefit.  Whenever  I  eat  anything  I  have  to  drink  a 
lot  of  water  to  push  it  througli  into  the  stomach.  Sometimes  it  will 
not  go  through  but  comes  back  up  again.  Otherwise,  I  am  apparently 
well." 

In  the  roentgenogram  (Fig.  12),  is  seen  the  characteristic  obstruc- 
tion with  dilatation  of  the  esophagus  above.  The  spasm  was  so  pro- 
nounced in  this  patient  that  half  the  motor  meal  was  retained  after 
six  hours.  Following  dilatation  of  the  constriction  bj'-  the  hydrostatic 
bag,  recovery  was  complete. 

CARCINOMA 

The  situation  in  order  of  frequency  of  esophageal  carci- 
nomata  has  been  variously  stated.  On  the  whole,  it  appears 
that  they  are  exceedingly  rare  from  the  introitus  to  the  tracheal 
bifurcation,  are  more  common  below  the  tracheal  bifurcation 
and  most  common  in  the  cardiac  portion. 

The  facility  with,  -which  esophageal  cancer  can  be  shown  by 
the  x-ray  depends  largely  upon  the  degree  of  obstruction. 
Those  w^hich  are  decidedly  obstructive  are  characterized,  as  a 
rule,  by  tortuous  irregularity  of  the  stenosed  lumen.  Above 
the  stenosis  there  may  be  some  dilatation,  but  this  is  usually 
less  marked  than  in  benign  obstruction.  Antiperistalsis  has 
been  noted  above  the  point  of  obstruction.  In  some  cases  of 
cancer  of  the  esophagus  not  involving  the  cardiac  opening, 
the  latter  remains  gaping,  wdthout  producing  the  usual  physio- 
logic retardation  of  the  material  s^vallow-ed. 

The  detection  of  early,  non-obstructive  cancers  is  more 
difficult.  The  esophageal  contour,  outlined  by  the  barium- 
acacia  mixture,  wdll  show  filling-defects  proportionate  to  the 
growth,  but  these  must  be  carefully  differentiated  from  the 
numerous  normal  irregularities.  In  a  few^  instances,  observers 
have  noted  reflex  esophageal  spasm  accompanying  early  cancers. 

Obstructive  carcinomata  must  be  differentiated  from  benign 
organic  and  spasmodic  strictures  and  from  pressure  stenoses. 
In  any  of  these  there  may  be  irregularity  of  the  esophageal 
lumen,  though  less  constantly  than  in  carcinoma.  Rarely,  a 
diverticulum  may  somewhat  resemble  the  roentgenologic   as- 


58  THE   ESOPHAGUS 

pects  of  esophageal  cancer,  and  diverticula  may  result  from 
obstructive  cancer.  In  many  cases  of  carcinoma  the  only 
roentgen  sign  found  will  be  some  degree  of  obstruction  and  a 
complete  diagnosis  can  be  made  only  by  taking  the  clinical 
features  into  account. 

Case  113,484,  male,  aged  64.  For  three  months  he  has  had  a  per- 
sistent dysphagia,  increasing  in  severity.  At  present  he  can  swallow 
no  solid  food  and  takes  semi-solids  and  liquids  with  difficulty.     He 


^ 


Fig.   19. — Carcinoma  of  the  esophagus.     Filling  defect  and  obstruction  a. 

regurgitates  stringy  mucus.  Attempts  at  swallowing  cause  some  pain 
under  sternum  radiating  to  back.  He  has  lost  45  pounds  in  nine 
months,  mostly  in  the  last  three  months,  and  has  grown  weaker. 

The  roentgenogram  (Fig.  19)  shows  obstruction  and  irregular 
filling-defects  in  the  mid-portion  of  the  esophagus.  The  denser  shad- 
ows are  produced  by  a  retention  of  the  six-hour  meal,  while  the  thin- 
ner shadow  above  is  the  barium  gruel  taken  at  the  time  of  examina- 
tion. Esophagoscopy  showed  a  cauliflower  carcinomatous  growth  in 
the  middle  third  of  the  esophagus. 

Case  120,943,  female,  aged  34,  Patient  states  that  when  a  child 
three  years  old  she  swallowed  some  acid  used  by  tinners  in  soldering. 
She  does  not  remember  any  subsequent  trouble  in  swallowing  until 


CARCINOMA 


59 


Fig.  20. — Carcinoma  of  the  esophagus.     Stenosis  with  irregular  filling 

defect,  a. 


Fig.  21. — Carcinoma  of  the  esophagus.     Irregular  obstruction  at  a. 


60 


THE   ESOPHAGUS 


one  year  ago  when  attempts  to  swallow  large  bits  of  meat  caused  chok- 
ing. Eight  months  ago  the  dysphagia  began  to  be  constant  and 
mouthfuls  of  food  were  regurgitated.  She  is  now  able  to  take 
liquids  only.  She  has  lost  about  30  pounds  during  the  last  eight 
months. 

The  roentgenogram  (Fig.  20)  indicates  irregular  obstruction  in  the 
middle  third  of  the  esophagus,  without  marked  dilatation  above. 


Fig. 


22. — Carcinoma    of    the    esophagus.     Infiltration   and   obstruction,    a.     Pulsion 
sac,  h.     Bismuth  in  left  bronchial  tree  inhaled  while  swallowing,  c. 


Esophagoscopic  examination:  Growth  in  the  middle  third  of 
esophagus,  thought  to  be  carcinoma. 

Case  133,217,  male,  aged  67.  Six  months  ago  began  to  hiccough 
at  meal  time.  Nothing  further  was  noticed  until  three  months  ago 
when  he  began  to  have  dysphagia,  the  pain  being  referred  to  the  upper 
sternal  region.     Later,   attacks  of  vomiting  commenced,  and  these 


CARCINOMA 


61 


Fig.  27.  Fig.  28. 

Figs,  23,  24,  25,  26,  27  and  28.     Illustrative  cases  of  cancer  of  the  esophagus. 


62  THE   ESOPHAGUS 

have  continued,  much  mucus  and  unsoured  food  being  ejected  with 
the  vomit.     Weight  loss,  20  to  30  pounds. 

Roentgenogram  (Fig.  21).  Obstruction  at  the  lower  third  is  well 
marked.     The  irregularity  of  contour  was  clearly  seen  on  the  screen. 

Case  44,345,  female,  aged  46.  Ten  months  ago  she  had  difficulty 
in  swallowing  which  diminished  for  a  month,  then  increased  until  for 
the  past  three  months  she  has  been  unable  to  take  solid  food.  The 
food  seems  to  stick  at  about  the  upper  border  of  the  sternum,  and  is 
quickly  regurgitated.     Weight  loss,  25  to  30  pounds. 

The  roentgenogram  (Fig.  22)  shows :  (a)  Irregular  obstruction  high 
in  the  esophagus,  (6)  pulsion  sac,  (c)  bismuth  in  right  bronchial  tree, 
inhaled  during  attempts  to  swallow. 

DIVERTICULUM 

The  classification  of  diverticula  into  ''pulsion"  or  "pressure" 
sacs  and  "traction"  sacs  is  generally  accepted.  The  pulsion 
sacs,  which  are  by  far  the  most  numerous,  are  produced  by 
internal  pressure  and  occur  nearly  always  at  the  pharyngo- 
esophageal  juncture  (the  introitus)  where  there  is  a  tendency  to 
deficient  musculature,  and  where  anomalies  in  closure  of  the 
lower  branchial  clefts  may  play  a  part.  Traction  sacs  result 
usually,  it  is  claimed,  from  gland  infection  about  the  left 
bronchus,  are  rare,  have  few  symptoms,  and  are  generally 
found  at  autopsy  only.  Pulsion  diverticula  commonly  have  a 
lateral  or  posterior  situation.  In  size,  diverticula  vary  from 
that  of  a  pea  to  that  of  a  very  large  pear.  When  filled  with  the 
opaque  mixture,  a  pulsion  diverticulum  commonly  shows  on 
the  screen  or  plate  as  a  symmetrical  sac  with  a  smooth,  rounded 
base.  In  exceptional  instances,  the  sac  may  appear  to  be  some- 
what irregularly  shaped  and  retained  food  bits  may  give  rise 
to  such  irregularity.  Its  fluid  contents  have  a  level  upper 
surface.  Its  position  with  reference  to  the  esophagus  can  be 
determined  usually  by  the  course  of  the  barium  through  the 
latter,  but  the  introduction  of  an  opaque  bougie  into  the  eso- 
phageal lumen  will  show  the  relations  better  on  the  screen  or 
in  the  roentgenogram.  The  sac  or  its  major  portion  lies  below 
its  opening  into  the  esophagus,  at  which  point  the  overflow 
drainage  into  the  esophagus  can  sometimes  be  observed. 


DIVERTICULUM 


63 


Dilatation  above  a  high-seated  carcinoma  or  benign  stric- 
ture may  somewhat  resemble  a  diverticulum,  and  this  resem- 
blance is  heightened  if  the  dilatation  has  become  pendant  so 
that  it  no  longer  drains  from  its  lowest  point.  In  carcinoma 
the  strictured  lumen  below  the  dilatation  is  commonly  irregular. 
It  is  noteworthy  that  diverticula  rarely  become  carcinomatous. 

Case  116,535,  male,  aged  55.  Seven  years  ago  he  began  to  have 
occasional  attacks  of  choking  with  food,  and  at  times  when  lying  down 


Fig.  29. — Diverticulum  of  the  esophagus,  a. 

felt  as  if  an  object  were  rising  in  his  throat  with  a  bubbling  sound 
then  falling  back  again.  The  choking  increased  in  severity  until  two 
years  ago.  Since  then  it  has  diminished,  but  the  amount  of  food  he  is 
able  to  take  has  also  diminished.  When  the  pocket  fills,  its  contents 
are  often  regurgitated  through  his  mouth  and  nose  two  to  five  times 
during  a  meal.  At  night  food  in  the  sac  causes  distress.  During  the 
past  year  he  has  formed  the  habit  of  taking  a  swallow  of  water  and  then 
expressing  the  contents  of  the  sac  by  massage  with  the  finger,  which 
enables  him  to  sleep  with  comfort.  He  is  obliged  to  chew  his  food 
well  and  swallow  slowly.  To  him  it  seems  that  no  food  goes  into  his 
stomach  until  the  pocket  is  filled,  and  then  there  is  a  choking  sensation. 


64  THE    ESOPHAGUS 

There  has  been  an  increasing  change  in  the  tone  of  his  voice  since  the 
trouble  set  in. 

During  the  screen  examination,  the  pocket  shown  in  the  roentgeno- 
gram (Fig.  29)  was  seen  to  fill  with  the  barium  gruel  after  which  the 
gruel  trickled  down  the  esophagus,  showing  that  the  sac  was  a  diver- 
ticulum.    Note  the  characteristic  situation  and  contour. 

Finding  at  operation:  Diverticulum,  size  of  lemon,  coming  off  the 
left  side  near  cricoid.     Excision  of  sac. 

Case  2492,  male,  aged  55.  For  eleven  j^ears  the  patient  at  times 
has  had  regurgitation  of  food  immediately  after  eating.     The  trouble 


Fig.  30. — Diverticulum  of  the  esophagus,  a. 

has  grown  worse  during  the  past  two  years,  and  although  he  has  a  good 
appetite  he  cannot  eat  with  satisfaction.  Food  regm'gitates  through 
the  nose  occasionally.  He  has  kept  to  his  bed  for  the  past  ninetj" 
days,  has  lost  strength  and  his  normal  weight  of  135  pounds  has  de- 
clined to  90  pounds. 

The  roentgenogram  (Fig.  30)  shows  a  very  large,  kidnej-shaped, 
diverticular  sac  coming  off  to  the  right  and  extending  upw^ard,  because 
of  less  resistance  in  that  direction.  It  gives  the  impression  that  the 
esophageal  opening  is  lower  than  the  highest  portion  of  the  sac,  but 
this  is  due  to  the  fact  that  the  neck  of  the  sac  and  the  esophageal  open- 
ing, which  is  higher  up,  are  not  visualized. 

Operative  findings:  Diverticulum,  right  side  of  esophagus,  Ij'ing 
under  sternum. 


CICATRICIAL    STRICTURES 


65 


Case  99,346,  male,  aged  66.  Dysphagia  with  regurgitation  began 
six  years  ago.  This  has  continued,  but  by  eating  slowly  he  gets  along 
fairly  well.  To  him  the  seat  of  obstruction  seems  to  be  just  below  the 
cricoid.     Liquids  give  more  difficulty  than  solids. 

Roentgenogram  (Fig.  31),  oblique  view.  Small  diverticular  sac 
coming  off  opposite  the  cricoid. 


EiG.   31. — Oblique  view  of  small  esophageal  diverticulum,  a. 


CICATRICIAL  STRICTURES 

Cicatricial  stenoses  may  be  the  result  of  a  healed  ulcer, 
either  simple,  tuberculous  or  syphilitic,  or  of  a  trauma,  such  as 
results  from  drinking  caustic  liquids.  In  traumatic  cases  the 
stricture  may  not  cause  dysphagia  until  many  years  after ^the 
receipt  of  the  injury.  Such  strictures  may  occur  at  any  point 
in  the  esophagus.  Often  the  esophageal  lumen  above  the 
stenosis  is  slightly  dilated  and  shows  a  rounded,  smooth,  sym- 
metrical termination,  from  which  a  thin  stream  of  barium 
trickles  through  the  stenosis.  Thus,  if  seated  high  up,  the 
condition  may  be  mistaken  for  a  diverticulum,  but  in  the  latter 


66 


THE    ESOPHAGUS 


Fig.  32. 


Fig.  33. 


Fig.  34. 


Fig.  35. 


Fig.  36.  Fig.  37. 

Figs.  32,  33,  34,  35,  36  and  37. — Illustrative  cases  of  diverticulum  of  the  esophagus. 


DIVERTICULA 


67 


\  ^'^ 


Fig.  38. 


Fig.  40. 


Fig.  39. 


Fig.  41. 


Fig.  42.  Fig.  43. 

Figs.  38,  39,  40,  41,  42  and  43. — Illustrative  cases  of  diverticulum  of  the  esophagus. 


68 


THE   ESOPHAGUS 


instance  the  drainage  is  from  the  upper  part  of  the  sac  and  not 
from  the  bottom  as  in  stenosis. 

Other  than  the  finding  of  obstruction  with  dilatation  above 
it,  both  of  which  of  course,  vary  in  degree,  the  roentgenologic 
appearance  of  benign  organic  stenoses  is  not  especially  character- 
istic, and  differentiation  from  other  obstructive  conditions  will 


1 


Fig.  44. —  Indention  due  to  aortic  arch,  a.     Benign  stricture  of  the  esophagus  with 
barium  trickling  through,  h. 

depend   upon   the   history   and   upon   data   elicited   by   other 
means. 


Case  118,020,  female,  aged  50.  When  five  years  old  this  patient 
swallowed  lye.  During  childhood  she  had  some  difficulty  in  swallow- 
ing, but  gradually  grew  better,  although  she  has  always  had  to  mas- 
ticate food  well  or  it  would  stick.  Seven  years  ago  she  thought  some- 
thing lodged  in  the  stricture,  as  she  was  obliged  to  take  liquids  only 


CICATRICIAL   STRICTURES 


69 


for  several  weeks.  A  similar  attack  came  on  rather  sudclenlj^  about 
three  weeks  ago. 

The  roentgenogram  (Fig.  44)  shows  marked  constriction  of  the 
esophagus  opposite  the  aortic  arch,  with  barium  trickling  through  the 
stricture.  The  indentation  caused  by  the  arch  can  be  noted.  The 
esophagus  is  somewhat  dilated  above  the  stenosis. 

Case  117,800,  male,  aged  2li  years.  Eight  months  ago  he  drank 
a  strong  solution  of  lye.     Since  then  he  has  been  unable  to  retain  any- 


FiG.  45. — Benign  obstruction  of  esophagus.     Stricture  at  a. 


thing  but  milk.  Solid  food  is  vomited  in  from  a  few  seconds  to  one 
hour  after  eating. 

The  roentgenogram  (Fig.  45)  shows  obstruction  in  the  middle  third 
of  the  esophagus,  with  dilatation  above. 

Case  122,779,  female,  aged  38.  Two  weeks  after  gastroenterostomy 
for  a  duodenal  ulcer  the  patient  developed  marked  dysphagia.  A 
stricture  was  found  by  the  esophagoscope.     Later,  a  gastrostomy  was 


70  THE   ESOPHAGUS 

performed.     At  this  time  no  evidence  of  malignancy  was  found,  but 
the  cause  of  the  stricture  was  never  determined. 

Roentgenogram,  Fig.  46.  Stricture  in  lower  third  of  esophagus, 
smoothly  regular,  and  evidently  not  malignant. 

SPASM 

Aside  from  spasm  at  the  cardia,  spasm  may  occur  also  any- 
where along  the  course  of  the  esophagus,  with  more  or  less 
consequent  obstruction.     Such  spasm  has  been  seen  as  a  reflex 


Fig.  46. — Benign  obstruction;  barium  trickling  through  stricture  at  a. 

from  early  carcinoma.  By  analogy  one  would  expect  spasm 
of  the  esophagus  as  an  occasional  reflex  from  gastric  irritations, 
just  as  gastric  spasm  is  sometimes  seen  in  duodenal  irritation. 
Barclay''  holds  that  a  small  esophageal  abrasion  or  ulcer  may 
set  up  a  spasm  of  such  severity  and  persistence  that  complete 
obstruction  may  result,  and  he  mentions  a  case  of  this  character 
in  his  experience.  He  believes  that  simple  or  peptic  ulceration 
of  the  esophagus  is  of  more  frequent  occurrence  than  is  com- 
monly taught.  Transitory  reflex  spasms  are  not  likely  to  be 
demonstrated,  unless  the  examiner  is  unusually  fortunate. 


FOREIGN   BODIES  71 

FOREIGN  BODIES 

The  foreign  bodies  which  are  now  and  then  found  lodged 
in  the  esophagus  include  coins,  dental  plates,  bones,  pins, 
buttons,  rings  and  the  innumerable  things  which  most  children 
and  some  adults  put  into  their  mouths.  The  point  of  lodge- 
ment may  be  anywhere  in  the  esophageal  course,  though  more 
often  at  the  anatomic  narrowings,  such  as  those  at  the  aortic 
arch  and  the  introitus.  Arrest  of  a  foreign  body  may  be  due 
to  an  organic  stenosis.  Demonstration  of  a  foreign  body  by  the 
roentgen-rays  depends  upon  its  size  and  density.  Small  bones, 
bone  buttons  and  cartilage  are  not  easy  to  detect  even  on  the 
plate.  Roentgenoscopic  localization  of  non-opaque  bodies  may 
sometimes  be  aided  by  giving  the  barium  mixture  and  discover- 
ing the  point  where  the  stream  is  obstructed  or  turned  aside. 
An  illustration  of  this  is  seen  in  Fig.  47. 

Case  101,410,  male,  aged  23-^  years.  Eleven  days  previously  he 
had  swallowed  a  coin  which  caused  vomiting  and  some  bleeding  from 
the  nose.  Since  then  he  has  been  unable  to  swallow  anything  except 
liquids. 

The  roentgenogram  (Fig.  47a)  shows  foreign  body  (coin)  high  in  the 
esophagus.  This  was  definitely  determined  by  screening  the  patient 
in  the  oblique  position. 

MISCELLANEOUS  ESOPHAGEAL  LESIONS 

Although  they  have  no  diagnostic  roentgenologic  signs, 
there  are  conditions,  other  than  those  mentioned  above,  the 
possibility  of  which  the  roentgenographer  must  bear  in  mind 
in  drawing  conclusions.  Cases  have  been  seen  of  paralysis  of 
the  gullet  in  which  the  patient,  while  unable  to  swallow  solids, 
could  take  liquids  readily.  Fistulous  communications  between 
the  esophagus  and  the  trachea  or  bronchus  exist  occasionally, 
occurring  as  a  result  of  wall-destruction  by  carcinoma  (Fig. 
48),  tuberculosis,  abscess  or  foreign  body.  In  such  cases,  the 
fistula  may  be  traced  by  the  course  of  the  opaque  mixture,  but 
this  method  of  examination,  because  of  its  obvious  possibilities 
for   evil,   is  hardly   to  be  recommended  when  the  history   is 


72 


THE    ESOPHAGUS 


Fig.  47. — Complete  obstruction  in  lower  third  of  esophagus  by  a  portion  of  beef  steak. 
Note  peristalsis  above  the  obstruction. 


Fig.  47a. — Coin  in  the  esophagus,  a. 


REFERENCES 


73 


indicative  of  the  condition.  Esophageal  piles  may  give  symp- 
toms of  obstruction,  but  no  cases  with  roentgenologic  signs  have 
been  reported.  The  authors  have  seen  one  case  of  bulbar 
palsy  in  which  the  barium  lagged  both  at  the  introitus  and  at 
the  cardia.  Although  infrequently  met  with,  esophageal  polyps 
sometimes  exist.  Stewart^  describes  them  as  having  their 
situation  high  in  the  esophagus,  being  usually  pedunculated 
and  sometimes  of  considerable  size.  Roentgenologicallyjthey 
simply  give  signs  of  obstruction. 


Fig.  48. — The  irregular  stenosis  due  to  the  cancer  is  seen  at  a.  Below  this  is  seen  the 
fistulous  tract  through  which  barium  has  passed  into  the  main  trunk  of  the  left  bronchus, 
h,  and  its  lower  branches  c.     Verification  by  autopsy. 


REFERENCES 

1.  HiRSCH,  I.  S.:    ''The  Roentgen-Ray   Study   of  the  Esophagus." 

Interstate  Med.  Jour.,  1916,  xxiii,  42-67. 

2.  Myer,  J.  S.  and  Carman,  R.  D.:   "Cardiospasm  with   Saccula- 

tion of  the  Esophagus,  with  Special  Reference  to  the  Persist- 
ence of  the  Sac."     Jour.  A.  M.  A.,  1912,  lix,  1278-1281. 

3.  Bassler,   a.:  "Early   Diagnosis   of   Cancer   of  the   Esophagus." 

Jour.  A.  M.  A.,  1913,  Ix,  1283-1284. 

4.  Crump,  A.  C:  "A  New  Aid  for  the  Diagnosis  of  Stricture  of  the 

Esophagus."     Jour.  A.  M.  A.,  1914,  Ixii,  1471-1473. 


74  THE   ESOPHAGUS 

5.  HoLZKNECHT,  G. :  ''Die  normale  Peristaltik  des  Kolon."     Muen- 

chener  Med.  Wchnschr.,  1909,  ii,  2401-2403. 

6.  Barclay,  A.   E.:   "The   Stomach  and  Esophagus."     Macmillan 

Co.,  New  York,  1915,  20. 

7.  Barclay,   A.  E.:  "The   Stomach  and   Esophagus."      Macmillan 

Co.,  New  York,  1915,  29-30. 

8.  Stewart,  W.   H.:   "The   Value  of  the  Rontgen  Examination  in 

Obstructions  of  the  Esophagus."     Arch,  of  Diagn.,   1913,   vi, 
309-314. 


CHAPTER  V 

THE  STOMACH 
TECHNIC 

The  examination  of  the  stomach  comprises  four  steps,  as 
follows:  (1)  preparation  of  the  patient;  (2)  administration  of 
a  six-hour  meal;  (3)  roentgenoscopic  examination;  and  (4) 
roentgenography. 

Preparation. — On  the  evening  previous  to  the  day  of  exami- 
nation, the  patient  is  permitted  to  eat  his  evening  meal  as  usual, 
or  the  special  meal  prescribed  by  the  gastroenterologist  if  the 
gastric  contents  are  also  to  be  examined.  He  is  instructed  to 
omit  breakfast  the  next  morning,  and  either  go  first  to  the 
gastroenterologist  for  examination  or  come  directly  to  the 
roentgen  laboratory. 

The  Six -hour  Meal. — At  the  laboratory  the  patient  is  given 
4  ounces  of  well-cooked  wheat  breakfast  food  in  which  has  been 
stirred  2  ounces  of  barium  sulphate.  To  this  he  may  add  milk 
(not  cream),  and  a  little  sugar  according  to  his  taste.  He  is 
directed  to  abstain  from  other  food  or  drink,  except  water, 
until  the  examination  is   completed. 

Roentgenoscopy. — Six  hours  later  he  returns  and  is  taken  to 
the  screen  room.  If  the  patient  be  a  man  he  is  stripped  to  his 
hips;  if  a  woman,  she  is  permitted  to  wear  a  thin  garment.  The 
patient  takes  his  position  in  front  of  the  vertical  screen  apparatus, 
with  his  back  against  the  celluloid  panel.  The  operator  sits 
on  a  stool  in  front  of  the  patient  and  screen.  By  means  of  the 
foot-switch,  the  room-illumination  is  turned  off  and  the  rays 
turned  on.  First,  the  chest  is  briefly  inspected.  Next,  the 
position  and  distribution  of  the  six-hour  meal  are  noted.     Then, 

75 


76  THE   STOMACH 

the  patient  takes  a  mixture  of  8  ounces  of  water  and  2  ounces  of 
barium  sulphate,  freshly  stirred.  While  he  is  drinking  this 
the  canalization,  that  is  to  say,  the  manner  in  which  the  ingested 
stream  descends  to  the  lower  portion  of  the  stomach,  is  observed. 
If  there  is  doubt  that  a  given  shadow  from  the  six-hour  meal 
represents  a  gastric  retention,  the  observer  notes  whether  or 
not  the  barium-water  merges  directly  with  the  suspected 
shadow.  When  the  patient  has  finished  drinking,  the  contents 
of  the  stomach  are  first  driven  by  the  pressure  of  the  operator's 
hand  toward  the  fundus  to  outline  its  contour.  Then  the  con- 
tents are  pressed  toward  the  pylorus.  Some  of  the  barium- 
water  usually  is  forced  out  into  the  duodenum  and  in  this  way 
the  location  of  the  pyloric  ring  can  be  determined. 

The  patient  is  next  given  a  second  mug  containing  12  ounces 
of  corn-starch-pap  with  barium  (see  page  27).  When  this 
has  been  drunk,  the  filled  stomach  is  inspected  and  its  general 
form,  contour,  size,  position,  mobility,  flexibility  and  peristalsis 
noted,  the  patient  being  rotated  for  different  angles  of  view, 
and  palpatory  manipulation  being  employed  as  necessary. 
The  oblique  \dew  is  never  omitted,  since  by  this  means  lesions 
on  the  anterior  or  posterior  wall  are  sometimes  discovered  when 
they  would  fail  to  show  in  the  postero-anterior  view.  The 
tube-box  diaphragm  is  used  freely,  narrowing  the  aperture  for 
close  study  of  particular  regions.  During  the  screen-examina- 
tion, special  attention  is  directed  to  the  pyloric  portion  of  the 
stomach  because  it  is  not  always  well  outlined  on  the  plate. 
If  the  barium  tends  to  settle  away  from  the  pylorus,  the  ingesta 
are  driven  toward  the  pyloric  end  by  manual  pressure.  Note  is 
taken  of  the  volume  and  character  of  the  flow  through  the  pylorus, 
whether  scant  or  copious,  intermittent  or  continuous.  The  ob- 
server follows  peristaltic  waves  from  their  commencement  to  their 
termination,  noting  whether  they  continue  without  interruption  to 
the  pyloric  ring,  and  observing  their  depth  on  each  curvature. 
Antiperistalsis  is  watched  for,  since  its  presence  is  almost  always 
associated  with  a  pathologic  condition  either  of  the  stomach  or 
duodenum.     It  is  seen  most  often  in  the  obstructive  lesions  at  or 


ROENTGEN    ANATOMY  77 

near  the  pylorus.  If  peristalsis  is  apparently  absent,  the  observer 
waits  a  bit  for  its  appearance.  Likewise,  when  duodenal  ulcer  is 
suspected,  the  study  is  continued  intermittently  for  several 
minutes,  if  necessary,  in  order  that  sufficient  time  may  elapse 
for  hyperperistalsis  to  appear.  If  pathologic  conditions  involv- 
ing the  upper  gastric  pole  are  surmised,  the  patient  is  examined 
also  on  the  fluoroscopic  table.  Here  the  dorsal  position  offers 
the  better  opportunity  for  palpation,  but  the  patient  is  examined 
prone  and  at  various  angles  in  addition.  When  the  screen- 
examination  is  concluded,  the  findings  are  entered  on  the  blank 
previously  mentioned  (Fig.   1). 

Plates. — Plates  are  made  immediately  after  the  screen- 
examination  is  completed.  The  patient  lies  prone  upon  the 
cassette,  the  tube  at  his  back  and  18  or  20  inches  distant  from 
the  plate.  He  is  instructed  to  remain  perfectly  still  and  refrain 
from  breathing  during  the  exposure.  Eleven  by  14-inch  plates 
are  used  as  a  rule,  but  by  careful  posing  10  by  12-inch  plates 
will  often  suffice.  The  8  by  10-inch  size  is  used  generally  for 
serial  or  multiple  plates  of  the  pyloric  and  duodenal  regions. 
In  making  plates  of  the  patient  lying  prone,  he  is  supported 
by  cushions  under  his  chest  and  thighs  if  his  abdomen  is  promi- 
nent, in  order  to  prevent  undue  abdominal  pressure  and  con- 
sequent distortion.  Lesions  high  in  the  cardia  are  sometimes 
better  shown  by  plates  made  with  the  patient  on  his  back  or 
even  in  the  Trendelenburg  position.  Plates  are  easily  made 
with  the  patient  standing,  and  this  is  done  often,  though  the 
upper  portion  of  the  stomach  is  not  usually  well  outlined. 

The  plates  are  compared  with  the  screen-observations  as 
noted  on  the  fluoroscopic  sheet,  and  the  net  findings  are  entered 
on  the  permanent  record  sheet  (Fig.  2). 

ROENTGEN  ANATOMY 

The  barium-filled  normal  stomach  as  seen  on  the  screen  or 
plate  differs  in  many  respects  from  the  stomach  described  in 
most  textbooks  of  anatomy.     However,  this  does  not  warrant 


78  THE   STOMACH 

the  conclusion  that  the  textbooks  are  wrong  and  that  the  roent- 
genologic stomach  is  an  absolute  standard.  Indeed  it  has  been 
urged,  and  with  reason,  that  the  roentgen  stomach  is  to  some 
extent  an  artefact,  that  the  differing  stomachs  shown  at  autopsy, 
in  the  opened  belly  of  the  living,  and  by  the  x-ray,  represent 
nothing  else  than  different  conditions  of  the  organ  according 
to  the  degree  of  filling,  the  character  of  the  filling  material, 
whether  food,  fluid,  air  or  barium,  the  contraction  of  the  gas- 
tric musculature,  the  degree  of  rigor  mortis,  the  changes  caused 
by  opening  the  abdomen  and,  finally,  the  conformation  of  the 
neighboring  organs.  But  the  roentgenologist  need  not  concern 
himself  with  absolute  standards;  he  is  interested  rather  in 
roentgenologic  bases  of  comparison. 

The  stomach  described  and  illustrated  in  textbooks  of 
anatomy  is  characterized  by  the  extreme  breadth  of  its  cardiac 
end,  the  fundus,  and  the  convergence  of  its  walls  to  form  a 
narrow  pyloric  portion.  The  majority  of  stomachs  as  observed 
by  the  aid  of  the  roentgen  ray  and  with  the  patient  standing  do 
not  show  this  wide  difference  between  the  diameters  of  the  car- 
diac and  pyloric  segments.  On  the  contrary,  the  usual  roent- 
genologic hook-form  stomach  is  tubular  rather  than  bulbous, 
and  its  pyloric  portion,  except,  of  course,  immediately  at  the 
pylorus,  is  almost  as  broad  as  its  cardiac  portion.  Further,  it 
occupies  a  position  which  is  largely  vertical,  instead  of  largely 
transverse,  as  customarily  shown  in  anatomical  drawings.  A 
relatively  infrequent  form  of  roentgenologic  stomach,  the  steer- 
horn,  does  lie  rather  crosswise,  but  it  bears  little  resemblance 
otherwise  to  conventional  illustrations  of  this  organ. 

Anatomists  customarily  divide  the  stomach  into  two  parts 
— a  cardiac  portion  (fundus)  and  a  pyloric  portion — some  roent- 
genologists follow  this  division.  Others  prefer  to  speak  of  a 
vertical  (cardiac)  portion  and  a  horizontal  (pyloric)  portion. 
This  is  applicable  to  certain  types  of  stomach.  Most  divisions 
are  based  on  the  hook-form  of  stomach,  and  one  of  these  dis- 
tinguishes descending,  transverse  and  ascending  portions.  A 
convenient  division  is  that  used  by  many  roentgenologists,  by 


ROENTGEN   ANATOMY 


79 


which  the  stomach  is  divided  into  pars  cardiaca,  pars  media 
and  pars  pylorica.  The  accompanying  drawings  illustrate  these 
divisions  in  both  the  common  forms  of  stomach  (Figs.  49  and  49a). 
The  pars  cardiaca  (fundus;  fornix;  antrum  cardiacum)  may 
be  regarded  practically  as  the  upper  third  of  the  stomach. 
According  to  some,  its  lower  limit  is  marked  by  the  incisura 


_,Gas    "butble  (MagenbUse) 


—  -Pars    mei^i 


PyloAs  CO. 

Fig.  49. — Steer-horn  stomach. 

cardiaca,  the  angle  above  the  junction  of  the  esophagus  with 
the  stomach.  However,  the  incisura  cardiaca  is  frequently 
confounded  with  a  shallow  indrawing  sometimes  seen  at  a 
considerably  lower  level  on  the  greater  curvature.  The  pars 
cardiaca  fits  snugly  under  the  left  arch  of  the  diaphragm.  It 
contains  the  gas-bubble  (magenblase)  within  its  upper  convexity. 


B'u.Xb'u.s    3ii-tod.eni,  \ 


Pylo 


.Gas    "biibUe  (KagenUase) 
j-PaTS   cardiaca 


pi|lorvca' 

Fig.  49a. — Fish-hook  stomach. 


When  the  stomach  is  filled,  the  base  of  the  gas-bubble  is  marked 
by  the  horizontal  plane  at  the  upper  surface  of  the  gastric 
contents.  Near  the  level  of  this  plane,  on  the  lesser  curvature, 
is  the  esophageal  opening. 

The  pars  media  (body;  corpus;  pars  intermedia)   extends 
from  the  pars  cardiaca  to  the  incisura  angularis.     The  incisura 


80  THE    STOMACH 

angularis  is  well  marked  in  the  fish-hook  stomach,  in  which  it 
is  constituted  practically  by  the  most  dependent  portion  of  the 
lesser  curvatm-e.  With  the  institution  of  peristalsis  the  incisura 
angularis  is  deepened  by  the  peristaltic  wave,  which  passes  on 
and  is  succeeded  by  another  wave  that  renews  and  deepens  the 
incisura.  But  it  is  inaccurate  to  conceive  of  the  incisura  angu- 
laris as  a  permanent,  non-moving  indentation  due  to  muscular 
contraction.  This  notion  is  doubtless  related  to  the  idea  of  an 
^'antral  sphincter,"  which  is  open  to  question,  as  will  be  seen 
hereafter.  The  pars  media  of  the  fish-hook  stomach  descends 
vertically,  or  a  little  obliquely  to  the  right,  from  the  pars 
cardiaca.  Its  walls  are  largely  parallel.  The  pars  media  of 
the  steer-horn  stomach  courses  obliquely  or  transversely  to  the 
right  from  the  pars  cardiaca,  and  its  walls  tend  to  approach  each 
other  progressively,  to  its  junction  with  the  pars  pylorica. 

The  third  segment,  the  pars  pylorica,  is  the  smallest  of  the 
three  divisions.  It  narrows  somewhat  from  its  beginning  at 
the  incisura  angularis  to  its  termination  at  the  pyloric  ring.  In 
the  fish-hook  stomach  it  occupies  a  rather  vertical  position,  while 
in  the  steer-horn  it  lies  either  transversely  or  obliquely  downward. 

The  term  antrum  (antrum  pylori;  antrum  pyloricum)  is 
often  applied  to  the  bulbous  expansion  of  the  pars  pylorica  in 
front  of  a  peristaltic  constriction.  Thus  its  size  is  variable. 
In  its  largest  extent  it  includes  the  whole  pars  pylorica,  with 
which  the  term  is  sometimes  used  more  or  less  synonymously. 

The  pyloric  ring  shows  as  a  hiatus  in  the  barium  shadow, 
approximately  from  an  eighth  to  a  quarter  of  an  inch  in  breadth, 
between  the  pars  pylorica  and  the  duodenal  bulb.  When  the 
pyloric  sphincter  relaxes,  the  barium  flowing  through  it  shows 
the  pyloric  canal,  centrally  placed,  and  of  varying  width  accord- 
ing to  the  degree  of  sphincteric  relaxation.  While  usually  the 
pyloric  hiatus  can  be  demonstrated,  it  may  not  be  observed 
because  of  an  overhanging  bulb,  failure  of  the  barium  to  pass 
the  sphincter,  or  an  unfavorable  angle  of  view. 

The  pars  cardiaca  and  pars  media  of  a  fish-hook  stomach 
are  sometimes  spoken  of  as  the  descending  arm,  and  the  pars 


ROENTGEN    ANATOMY  81 

pylorica  as  the  ascending  arm.  The  length  of  the  ascending 
arm,  and  hence  the  height  of  the  pyloric  opening  above  the 
lowest  point  on  the  greater  curvature,  is  the  hubhohe  of  Haudek. 
The  upper  pole  of  the  stomach  is  the  dome  of  the  pars  cardiaca, 
while  the  lower  pole  is  the  most  dependent  arc  of  the  greater 
curvature. 


CHAPTER  VI 
THE  NORMAL  STOMACH 

It  is  rather  trite  to  say  that  a  knowledge  of  normal  condi- 
tions as  revealed  by  the  roentgen-ray  is  essential  to  a  proper 
understanding  of  abnormal  conditions.  Yet  this  general  truth 
applies  so  accurately  and  specifically  to  the  roentgenology  of 
the  stomach  that  its  reiteration  is  never  amiss.  The  ironical 
aphorism  is  sometimes  ventured  that  there  is  no  normal 
stomach.  By  this  is  meant,  of  course,  that  there  is  no  standard 
normal  roentgenologic  stomach.  Stomachs  which  are  markedly 
dissimilar  in  their  roentgenologic  characteristics  may  each  be 
appropriate  for  its  possessor  and  functionate  in  a  normal  manner. 
Nevertheless,  while  the  appearances  of  the  stomach  as  seen  in 
the  roentgenogram  are  almost  protean,  these  variations  have 
limits,  even  though  wide,  which  can  be  determined  in  a  general 
way. 

In  determining  whether  or  not  a  given  stomach  is  normal, 
account  must  be  taken  of  its  length,  breadth,  capacity,  contour, 
position,  form,  tonus,  mobility,  peristalsis  and  motility.  Now 
these  numerous  and  varying  factors  not  only  mutually  affect 
each  other,  but  they  are  also  modified  markedly  by  the  general 
body-form — the  habitus — of  the  individual.  Whoever  has 
examined  a  large  number  of  stomachs  and  noted  their  relation 
to  frame-structure  must  certainly  feel  that  the  stomach  nor- 
mally corresponds  to  the  type  of  body,  just  as  facial  character- 
istics distinguish  races.  The  general  "build"  of  the  individual 
thus  becomes  a  matter  of  prime  importance. 

Habitus. — Stiller^  has  emphasized  the  enteroptotic  habitus 
(asthenic  or  atonic  habitus,  asthenia  universalis  congenita),  and 
its  relation  to  disorders  of  the  abdominal  and  thoracic  viscera. 
Extreme  mobility  of  the  tenth  rib  is  a  stigma  of  the  enteroptotic 

82 


HABITUS  83 

habitus,  which  is  further  characterized  grossly  by  a  sUght 
skeleton,  a  long  narrow,  shallow,  sunken  thorax,  steeply  falling 
ribs,  wide  intercostal  spaces,  an  acute  epigastric  angle,  a  thin, 
weak  musculature,  a  poor  panniculus,  and  pallor  of  the  skin. 
This  habitus  is  prone  to  visceral  ptoses  and  ''vegetative  neuras- 
thenia." The  stomach  of  an  enteroptotic  person  is  usually  a 
long,  capacious,  vertically  lying,  relaxed,  pendulous  sac. 

Contrasting  strongly  with  the  enteroptotic,  is  the  broad, 
or  apoplectic  habitus,  with  its  robust  frame  and  musculature, 
its  short,  elevated,  broad  and  deep  thorax,  ribs  running  almost 
horizontally  to  the  sides,  narrow  intercostal  spaces,  and  obtuse 
epigastric  angle.  In  the  broad  habitus  the  stomach  is  main- 
tained at  a  high  level  in  the  abdomen,  is  relatively  short  and 
small,  and  tends  to  lie  obliquely  or  transversely. 

Between  these  extremes  is  the  normal  habitus,  neither  broad 
nor  enteroptotic,  varying  within  these  limits,  and  hardly  capable 
of  exact  definition.  In  the  normal  habitus  the  stomach  is  of 
medium  length  and  capacity,  and  lies  vertically  or  a  trifle 
obliquely  in  the  abdomen. 

Taking  the  epigastric  angle — the  angle  between  the  costal 
margins,  Avith  the  ensiform  at  the  apex — as  a  measure,  Stiller 
classifies  an  angle  of  twenty-five  degrees  or  less  as  enteroptotic, 
fifty  to  eighty  degrees  as  normal,  and  one  hundred  and  twenty 
to  one  hundred  and  forty  degrees  as  broad. 

The  photographs  herewith  show  the  three  types  of  habitus 
with  their  accompanying  types  of  stomach.  During  the  screen 
examination  the  outline  of  the  stomach  was  drawn  on  a  glass 
plate  with  soft  crayon,  marking  also  the  epigastric  angle,  the 
umbilicus  and  the  anterior  superior  iliac  spines.  The  drawing 
was  then  transferred  to  paper  by  contact  with  pressure,  and  this 
in  turn  was  applied  to  the  patient's  abdomen.  The  outline 
was  then  filled  in  with  lamp-black  to  indicate  the  barium-filled 
portion  of  the  stomach,  and  the  patient  was  photographed. 

Figures  50  and  51  illustrate  two  examples  of  the  normal 
habitus.  The  man,  in  Fig.  50,  has  a  typically  normal  build. 
His  stomach  is  of  moderate  size,  and  the  lower  pole  is  exactly 


84 


THE   NOEMAL   STOMACH 


at  the  umbilicus.     The  woman,  in  Fig.  51,  may  also  be  rated 
as  of  the  normal  habitus,  though  there  is  an  inclination  to  the 


Fig.  50. — Normal  habitus.  Fig.   51. — Normal  habitus,  inclining  to 

the  broad. 


Fig.  52. — Broad  habitus. 


broad  type.  Her  stomach  is  of  medium  size.  The  pylorus  is 
not  much  above  the  level  of  the  lowest  sweep  of  the  lesser  curva- 
ture.    The  lower  gastric  pole  is  at  the  umbilicus.     The  man 


H.JlBITUS 


85 


shown  in  Fig.  52  is  a  definite  example  of  the  broad  habitus. 
His  musculature  is  well  developed,  his  chest  broad,  and  his 
trunk  short.     His  stomach  is  quite  in  keeping  with  his  body 


Fig.  53. — Enteroptotic  habitus. 


Fig.   54. — Enteroptotic   habitus  of 
moderate  degree. 


Fig.   55. — ^Lo-n-  stomach,  the  result  of  abdominal  relaxation  rather  than  an 
enteroptotic  habitus. 

form,  and  sweeps  in  a  broad  curve  across  the  upper  abdomen. 
The  woman  in  Fig.  53  has  the  typical  enteroptotic  habitus. 
Her  musculature  is  poorly  developed,  and  her  trunk  is  long  and 


86  THE   NORMAL   STOMACH 

narrow.  Her  stomach  is  likewise  long  and  its  lower  pole  is  well 
down  in  the  pelvic  basin.  The  man  in  Fig.  54  also  is  enterop- 
totic  though  of  less  pronounced  degree.  His  stomach  is  quite 
long  and  broad,  and  its  lower  pole  is  a  handsbreadth  below  the' 
umbilicus. 

The  Abdominal  Wall. — A  second  factor  which  modifies  the 
form  and  position  of  the  stomach  is  the  tension  of  the  abdominal 
wall.  With  a  wall  of  good  tone,  other  things  being  equal,  the 
stomach  and  abdominal  viscera  will  be  held  up  at  a  higher 
level  than  if  the  wall  be  lax.  The  markedly  flaccid  belly,  fre- 
quently seen  in  multiparas,  or  after  the  removal  of  large  tumors 
or  ascitic  fluid,  is  often  accompanied  by  extensive  ptoses.  In 
Stiller's-  opinion,  the  flaccid  abdomen  has  been  confounded  by 
some  roentgenologists,  Holzknecht,  for  example,  with  the  habitus 
enteroptoticus,  which  latter  Stiller  limits  to  a  congenital  form 
of  body  with  a  flat,  rather  than  pendulous  belly. 

Fig.  55  illustrates  the  effect  of  relaxation  of  the  abdominal 
wall.  The  woman  can  ha.rdly  be  described  as  of  the  enteroptotic 
habitus.  She  is  beyond  middle  age  and  has  borne  children. 
Her  abdomen  is  lax  and  pendulous,  and  her  stomach  is  corre- 
spondingly long  and  low-placed. 

The  tension  of  the  abdominal  wall  varies  not  only  with  its 
general  tone  but  also  with  its  degree  of  active  contraction  as 
determined  consciously  or  unconsciously  by  the  patient  himself. 
During  examination  a  phlegmatic  person  is  likely  to  show  his 
natural  and  accustomed  abdominal  tension,  while  a  nervous 
or  apprehensive  individual  is  apt  to  contract  his  abdominal 
muscles  strongly. 

Gastric  Tonus. — A  third  factor  affecting  the  form,  position 
and  size  of  the  stomach  is  the  tone  of  the  gastric  musculature — 
its  capacity  of  contracting  upon  and  adapting  itself  to  its  con- 
tents. However,  gastric  tonus  is  judged,  from  the  roentgeno- 
logic standpoint,  largely  by  the  gastric  form,  position  and  size, 
all  of  which  are  widely  influenced  by  the  habitus,  the  abdominal 
tension  and  other  elements.  The  subject  of  tone  will  presently 
be  considered  further. 


FORM  87 

Finally,  the  form  and  position  of  the  stomach  are  influenced 
to  some  extent  by  the  conformation  of  adjacent  organs,  by  the 
character  of  the  filling  material  and  by  its  amount. 

Thus,  the  attributes  and  appearances  of  the  roentgenographic 
stomach  are  so  closely  interrelated  that  a  roentgenologic  esti- 
mate of  any  single  quality  is  comparative  rather  than  absolute, 
and  only  valid  in  proportion  to  the  carefulness  with  which  all 


Fig.  56. — Normal  steer-horn  stomach. 

contributing  elements  are  considered.  Nevertheless,  by  usage, 
certain  arbitrary  bases  of  comparison  have  become  established, 
which  are  convenient,  and  which  will  not  mislead  if  they  are 
considered  in  association  with  each  other. 

Form. — As  a  rule,  the  normal  adult  stomach  takes  one  of  two 
general  forms,  the  steer-horn  or  the  fish-hook. 

The  steer-horn  stomach,  so-called  because  of  its  resemblance 
to  the  horn  of  a  steer,  occurs  much  less  frequently  than  the  fish- 
hook. The  steer-horn  is  seen  normally  in  association  with  the 
broad  habitus,  whether  in  man  or  w^oman,  although  this  type 


88  THE   NORMAL   STOMACH 

of  body  is  seen  most  commonly  in  males.  Relatively  small,  as 
a  rule,  it  is  broadest  at  the  fundus  and  narrows  progressively 
to  the  pylorus  which  is  its  most  dependent  portion.  It  occupies 
an  oblique,  sometimes  almost  transverse,  position  and  lies 
well  above  the  umbilicus  (Fig.  56). 


Fig. 


Fig.  58. 


Fig.  59.  Fig.  60. 

Figs.  57,  58,  59,  and  60. — Normal  stomachs  of  steer-horn  form. 

The  fish-hook  is  by  far  the  most  common  form  of  stomach 
met  with.  It  resembles  a  hook  or  the  letter  J.  It  descends  more 
or  less  vertically  from  the  diaphragm,  curves  across  the  spine, 


FORM  89 

and  ascends  to  the  pylorus,  which  latter  lies  above  the  level  of 
the  lowest  point  on  the  lesser  curvature.  It  is  the  usual  associate 
of  the  slender  and  the  normal  habitus,  but  may  occur  also  with 
the  broad  habitus  (Fig.  61). 


Fig.   61. — Xormal  stomach  of  fish-hook  form. 

Between  the  typical  steer-horn  and  typical  fish-hook,  forms 
are  sometimes  seen  which  are  difficult  to  classify,  as  they  possess 
some  of  the  characteristics  of  both  (Fig.  70).  Further,  what 
seems  to  be  a  steer-horn  with  a  small  amount  of  ingesta,  may 
assume  a  fish-hook  form  if  its   contents  be  increased,   either 


90 


THE   NORMAL  STOMACH 


because  of  the  sagging  produced  by  the  additional  weight,  or 
its  lengthening  to  accommodate  a  greater  volume. 

Holzknecht'^  has  defined  the  normal  stomach  as  one  which  in  the 
upright  position  and  a  fihed  condition  has  the  pylorus  for  its  lowest 
point,  which  is  above  the  umbilicus.     It  is  of  steer-horn  form  with  a 


Fig.  62. 


Fig.  63. 


Fig.  64.  Fig.  65. 

Figs.  62,  6-3,  64  and  65. — Normal  stomachs  of  fish-hook  form. 

broad,  vertical,  cardiac  portion  and  a  narrow,  horizontal  pyloric  seg- 
ment. Holzknecht  states  repeatedly  that  the  pylorus  should  be  the 
lowest  point,  on  the  ground  that  this  is  the  optimum  for  its  function. 
His  observations  were  made  in  1906  and  are  not  necessarily  represen- 


FORM 


91 


tative  of  his  present  views.  However,  this  may  be,  Cannon*  points 
out  that  this  conception  of  the  normal  stomach  rests  upon  the  assump- 
tion that  the  stomach  is  emptied  by  gravity  drainage.  Cannon  holds 
that  the  contents  of  the  alimentary  canal  are  in  exact  equilibrium,  even 
in  the  standing  position,  that  '^ drainage"  in  the  common  usage  of  that 
term  is  impossible,  and  that  muscular  contraction  is  necessary  to  move 
food  onward  through  the  alimentary  canal. 


Fig.  66. 


Fig.  67. 


\ 


Fig.  68. 
Figs.  66,  67,  68  and  69. 


Fig.  69. 
-Normal  stomachs  of  fish-hook  form. 


Certainly  the  steer-horn  form  of  stomach  is  so  rare  that  if  this  be 
the  only  normal  stomach  then  more  than  90  per  cent,  of  all  stomachs 
must  be  abnormal.  We  find  it  difficult  to  believe  this,  since  hundreds 
of  fish-hook  stomachs  which  we  have  examined  were  found  to  be  ana- 
tomically normal  at  exploration  during  the  course  of  an  abdominal 
operation  for  other  conditions.     In  short,  we  feel  that,  barring  ex- 


92 


THE    NORMAL   STOMACH 


treme  exaggerations,  the  general  form  of  the  stomach  has  far  less 
significance  than  the  manner  in  which  it  performs  its  functions. 

Tone. — According  to  Schlesinger's''  classification,  which  has 
received  rather  general  acceptance,  four  varieties  of  tonus  are 
distinguished — the  orthotoiiic,  hypertonic,  hypotonic  and  atonic 
(Fig.  71). 

He  regards  the  orthotonic,  or  normal-toned,  stomach  as  one 
which  contracts  upon  its  contents  with  sufficient  force  to  main- 


[FiG.  70. — Normal  stomach  of  type  between  the  steer-horn  and  fish-hook  form. 


tain  a  tubular  form,  even  with  a  moderate  amount  of  ingesta.. 
The  orthotonic  stomach  is  assumed  by  Schlesinger  to  be  normal 
because  most  frequently  seen  and  because  it  performs  its  func- 
tions in  a  normal  manner.  It  is  of  fish-hook  form  and  of  uni- 
form diameter,  its  walls  being  parallel  nearly  to  the  pylorus 
where  they  converge  bluntly,  and  its  lower  border  is  at  or  near 
the  umbilicus. 

Schlesinger's  hypertonic  stomach,  as  the  term  indicates, 
shows  an  excess  of  tonicity.  It  is  short,  has  a  small,  flattened 
gas-bubble,  is  broadest   at   the   cardia,  and  its  walls  narrow 


TONE 


93 


steadily  to  the  pylorus,  giving  it  a  steer-horn  form  and  an  ob- 
lique or  transverse  position.  Its  lower  border  is  well  above  the 
umbilicus.     The  hypertonic  stomach,  though  relatively  infre- 


n 


IE 


nz 


CO. 


Fig.  71. 


-Schlesinger's  classification  of  stomachs  according  to  tone.     I,  Hypertonic; 
II,   orthotonic;  III,   hypotonic;  IV,   atonic. 


quent,  is  not  pathologic.  Schlesinger  regards  it  as  the  primary 
type  from  which  other  types  have  developed  by  the  stretching 
and  sagging  of  its  walls. 

His  conception  of   a  hypotonic  stomach  is  one  which  evi- 


94  THE   NOEMAL   STOMACH 

dences  relaxation  of  its  longitudinal  muscle-fibers  by  an 
increase  of  length,  and  consequent,  sagging  downward.  The 
circular  fibers  are  also  relaxed  and,  with  the  patient  standing, 
the  barium  meal  broadens  the  diameter  of  the  lower  pole, 
which  sinks  below  the  umbiHcus.  The  upper  pars  media  is 
somewhat  narrowed  by  the  tendency  to  approximation  of  its 
vertical  walls. 

Schlesinger's  atonic  stomach  shows  relaxation  to  an  extreme 
degree.  Ingesta  which  would  completely  fill  an  orthotonic 
stomach  now  merely  fill  the  expanded,  basin-like  lower  pole. 
The  vertical  walls  of  the  pars  media  approach  each  other,  closely 
enough  in  some  instances  to  retard  momentarily  the  descent  of 
barium.  The  lower  border  of  the  stomach  is  well  down  in  the 
pelvis.  The  gas-bubble,  without  support  below  to  give  it  a 
semilunar  shape,  appears  fusiform.  Though  not  normal,  the 
atonic,  as  Barclay^  pertinently  remarks,  should  be  discussed  in 
connection  with  the  normal  stomach,  for  it  is  a  ''defective 
physiological  action  rather  than  a  pathologic   condition." 

While  Schlesinger's  classification  is  more  or  less  diagram- 
matic, it  serves  as  a  satisfactory  scale  for  comparisons.  In  its 
practical  appHcation  it  is  subject  to  the  following  quahfications : 

1.  The  ''atonic  stomach"  of  clinicians  is  not  represented 
solely  by  the  atonic  stomach  of  Schlesinger,  for  the  frequency 
with  which  "atony"  is  used  in  a  clinical  sense  justifies  the  as- 
sumption that  it  is  applied  to  all  degrees  of  hypotonus. 

2.  Schlesinger  limits  the  hypertonic  stomach  to  the  stomach 
of  steer-horn  shape.  But  fish-hook  stomachs  are  often  seen 
which  are  undoubtedly  hypertonic  as  shown  by  their  extremely 
narrow  diameter,  shortness,  and  high  position,  although  the 
hook-form  is  retained. 

3.  He  regards  only  the  hypertonic  and  orthotonic  types  as 
normal.  In  a  narrow  sense  this  is  perhaps  true,  but  hypotonic 
stomachs  are  often  seen  which  are  in  keeping  with  the  entero- 
ptotic  habitus  of  their  possessors,  and  which  perform  their 
functions  in  a  normal  manner. 

Thus  w^e  feel  that  the  chief  test  by  which  the  stomach  is  to  be 


POSITION  95 

adjudged  of  normal  tone  is  its  correspondence  to  the  habitus  of  the 
individual,  and  not  its  form,  size  and  position  alone.  With 
the  broad  habitus  the  tone  may  vary  from  orthotonus  to  hyper- 
tonus.  With  the  normal  habitus  it  may  be  expected  to  vary 
from  orthotonus  to  at  least  slight  degrees  of  hypotonus.  With 
the  enteroptotic  habitus,  hypotonus  is  the  rule,  not  only  of  the 
stomach,  as  Stiller  has  pointed  out,  but  of  other  organs  as  well, 
and  the  gastric  hypotonus  should  not  be  given  undue  or  exclu- 
sive stress. 

Again,  strictly  speaking,  tonus  is  an  intrinsic  quality  of  the 
gastric  musculature,  but  the  position,  form  and  size  of  the 
stomach  are  modified  not  only  by  varying  degrees  of  gastric 
tone  but  also  by  the  intra-abdominal  pressure  and  the  amount 
of  ingesta.  Increased  intra-abdominal  tension  tends  to  lift 
up  and  shorten  the  stomach;  diminished  tension  tends  to  lower 
and  lengthen  the.  stomach.  Hence  the  tonicity  of  the  abdom- 
inal wall  as  well  as  conditions  within  the  belly,  such  as  ascites, 
pregnancy,  new  growths,  etc.,  must  be  considered  in  estimating 
the  actual  tonus.  Further,  gastric  tonus  may  vary  to  some 
extent  at  different  times  in  the  same  individual,  and  at  different 
stages  of  digestion. 

Position. — It  should  be  sufficiently  clear  from  the  foregoing 
that  the  position  of  the  lower  gastric  pole  has  a  wide  range 
within  normal  limits,  and  it  may  lie  well  above  or  well  below  the 
umbilicus,  the  level  of  which  grossly  corresponds  to  a  line  joining 
the  iliac  crests.  The  position  of  the  lower  pole  is  affected  also 
by  respiration,  being  lowered  slightly  in  inspiration  and  raised 
slightly  in  expiration. 

The  position  of  the  pylorus  varies  rather  widely  with  the 
form  of  the  stomach,  the  habitus  of  the  individual  and  the  posi- 
tion of  neighboring  organs.  Thus  the  pylorus  of  the  steer-horn 
stomach  often  lies  far  above  the  umbilical  level,  high  up  in  the 
right  hypochondrium.  The  pylorus  of  the  fish-hook  stomach 
is  usually  slightly  to  the  right  of  the  median- line  and  somewhat 
above  the  umbilicus.  But  a  low-lying  stomach  may  have  its 
pylorus  even  below  the  umbilical  level  and  in  the  median  line. 


96 


THE    NORMAL   STOMACH 


The  pylorus  of  an  acute  fish-hook  stomach  is  often  to  the  left 
of  the  median  line. 

The  cardiac  end  of  the  stomach  does  not  vary  its  position 
normally.  Noteworthy  is  the  fact  that  the  stomach  descends 
from  the  upper  pole  with  a  slight  obliquity  forward  so  that  its 
lower  pole  is  closer  to  the  abdominal  wall  than  is  its  upper  pole. 
For  this  reason  the  roentgen  shadow  of  the  lower  gastric  segment 
is  sharper  in  the  anterior  view  than  that  of  the  cardiac  segment 
(Fig.  72). 

r 


Fig. 


72. — Lateral   view,    diagrammatic,    sliowing   the   more   anterior   situation   of   the 
lower  gastric  pole. 


When  the  patient  lies  on  his  back  on  the  screen-table,  the 
stomach  shows  a  wide,  oval  pars  cardiaca  and  pars  media,  while 
the  pyloric  portion  seems  narrowed,  or  may  not  be  seen  at  all, 
thus  giving  a  greater  resemblance  to  the  traditional  sac-form 
of  the  anatomists.  In  the  prone  position  also,  the  stomach  lies 
higher  than  when  the  patient  is  standing;  the  cardiac  end  is 
broader  and  the  pyloric  end  narrower. 

Size. — The  normal  stomach  is  a  potential  cavity.  Its 
apparent  size  depends  therefore  on  the  volume  of  its  contents. 
The  stomach  accommodates  itself  to  an  increasing  volume  of 


MOBILITY  97 

contents  chiefly  by  an  increase  of  width,  but  partly  also  by  an 
increase  of  length.  The  expansibility  in  all  directions  with  an 
increase  of  the  gastric  contents  is  a  noteworthy  feature  of  the 
normal  gastric  wall.  An  orthotonic  adult  stomach  will  ordi- 
narily accommodate  24  fluid  ounces  of  a  barium  mixture  with- 
out discomfort  to  the  patient,  and  by  this  amount  the  gastric 
periphery  will  be  effectively  visualized.  A  hypertonic  stomach 
may  hold  this  quantity  but  with  rather  evident  distention. 
Capacity  is  increased  proportionately  to  loss  of  tone.  A  24- 
ounce  barium  meal  does  not  completely  fill  a  hypotonic  stomach, 
but  abdominal  palpation  or  the  institution  of  peristalsis  may 
increase  the  gastric  tone  until  the  barium  is  forced  well  up  to  the 
gas-bubble.  In  megalogastria  the  stomach  may  be  of  enormous 
size  and  yet  functionate  properly.  Ewald^  mentions  one  with 
a  capacity  of  1680  c.c.  (56  ounces).  On  the  other  hand,  the 
smallest  normal  stomach  he  noted  could  accommodate  only 
250  c.c.  (8  ounces). 

Contour.^ — The  otherwise  smooth  and  regular  contour  of  the 
normal  stomach  is  broken  by  the  incisura  cardiaca,  the  incisura 
angularis  and  by  peristaltic  waves.  As  stated  before,  the 
incisura  cardiaca  is  the  upper  angle  at  the  junction  of  the 
esophagus  with  the  stomach.  The  incisura  angularis  is  the  deep 
depression  on  the  lesser  curvature  at  the  junction  of  the  pars 
media  and  pars  pylorica. 

On  the  greater  curvature,  about  where  the  left  costal  arch 
crosses  the  stomach,  a  broad,  shallow,  incurvation  is  frequently 
seen,  especially  if  the  abdomen  be  rigid  or  retracted,  and  is 
probably  due  to  the  pressure  of  the  abdominal  muscles,  although 
some  observers  have  attributed  it  to  the  spleen.  Hypotonic 
stomachs  also  sometimes  have  a  long  sweeping  incurvation  of 
the  greater  curvature  of  the  pars  media. 

The  contour  of  the  pyloric  end  varies  with  the  peristalsis 
of  the  antrum,  but  is  always  normally  symmetrical  at  any  stage 
of  contraction. 

Mobility. — The  principal  fixing  supports^  of  the  stomach 
are  the  esophagus  and  gastro-phrenic  ligament  at  its  cardiac 


98  THE    NORMAL   STOMACH 

end,  and  the  hepato-duodenal  ligament,  about  an  inch  beyond 
the  pylorus.  Between  these  points,  the  dependent  body  of  the 
fish-hook  stomach  has  a  considerable  range  of  passive  move- 
ment, and  by  palpatory  maneuvers  can  be  lifted  up  or  shifted 
to  either  side.  By  drawing  in  or  relaxing  the  abdominal  wall 
most  patients  can  raise  or  lower  or  even  distort  the  stomach  at 
will  (Fig.  73) .  By  deep  respiration  the  filled  stomach  may  be 
lowered  during  inspiration   and  raised  during  expiration,   the 


Fig.   73. — Stomach  distorted  by  strong  retraction  of  the  abdominal  wall. 

change  sometimes  affecting  the  cardia  and  media  chiefly,  or  it 
may  be  slightly  raised  and  lowered  en  masse. 

The  hypertonic  steer-horn  stomach,  lying  high  under  cover 
of  the  costal  arches,  between  which  the  abdominal  wall  is  less 
lax,  is  not  freely  accessible  to  palpation  and  hence  not  easily 
moved  about.  The  pendulous,  hypotonic  stomach  is  susceptible 
of  wide  shifting.  In  estimating  mobility  the  relative  tension 
of  the  abdominal  wall  should  be  taken  into  account,  accordingly 
as  it  facilitates  or  hinders  manipulation. 


FLEXIBILITY  99 

Flexibility. — An  important  characteristic  of  the  normal 
gastric  wall  is  its  flexibility.  With  the  abdominal  wall  fairly 
relaxed,  narrow  palpation,  i.e.,  with  a  single  finger  or  the  ulnar 
side  of  the  hand,  on  the  greater  curvature,  will  produce  a  sharply 
outlined  indentation  closely  corresponding  to  the  palpated 
surface.  If  the  abdomen  is  held  rigid,  as  often  happens,  this 
maneuver  is  less  practicable  and  less  effective. 

Gas-bubble. — In  the  upper  pole  of  the  stomach  is  a  quite 
constant  transparent  area,  the  gas-bubble,  chiefly  due  to  swal- 
lowed air.  Its  convex  upper  surface  fits  into  the  concavity  of 
the  left  diaphragm.  With  an  empty  or  partially  filled  stomach 
its  base  projects  downward  like  a  spindle.  With  a  filled  stomach 
its  base  becomes  a  transverse  plane,  level  with  the  cardiac  end 
of  the  esophagus.  Its  size  varies  considerably  and  without 
special  significance.  In  the  hypertonic  stomach  it  is  usually 
small  and  somewhat  flattened,  while  in  the  orthotonic  or  hypo- 
tonic stomach  it  is  more  convex  above  and  larger.  In  the 
markedly  hypotonic  stomach  the  gas-bubble  is  fusiform  or 
balloon-shaped. 

Secretion. — The  amount  of  secretion  in  the  normal  fasting 
stomach  is  so  small  that  no  accurate  estimate  can  be  made 
during  the  ordinary  roentgen  examination.  After  filling  the 
stomach  with  the  barium-pap  an  intermediate  layer  of  fluid 
may  usually  be  seen  between  the  gas-bubble  above  and  the 
barium-emulsion  below.  This  fluid  is  partly  gastric  secretion 
but  mostly  water  which  has  separated  from  the  media  employed. 
Hence  the  depth  of  the  layer  varies  not  only  with  the  amount 
of  secretion  but  also  with  the  amount  of  water  which  happens 
to  separate,  and  is  not  a  reliable  index  of  secretory  activity. 

To  determine  the  amount  of  secretion  in  the  fasting  stomach, 
Kaestle^  has  made  use  of  Sahli's  opaque  capsules;  one,  the 
''swimming"  capsule,  floats  upon  the  surface;  the  other,  the 
''sinking"  capsule,  falls  to  the  bottom.  The  vertical  distance 
between  the  capsules  measures  the  depth  of  the  secretion-pool. 
However,  the  total  quantity  of  secretion  depends  not  only  upon 
its  depth,  but  also  upon  the  breadth  of  the  lower  gastric  pole. 


100  THE    NORMAL   STOMACH 

To  our  mind  the  amount  of  secretion  can  be  determined  more 
accurately  by  the  gastroenterologist's  tube  than  by  roentgen 
methods. 

To  measure  the  digestive  power  of  the  stomach,  Schwarz^'^ 
has  employed  opaque  ^'fibrodermic"  capsules.  The  capsule 
itself  is  digestible  and,  when  dissolved,  releases  its  opaque 
contents.  The  time  required  for  this  can  be  determined  by 
examination  at  frequent  intervals. 

Peristalsis. — The  ring-like  constrictions  encircling  the  stom- 
ach which  progress  to  the  pylorus,  stroking  the  gastric  contents 
toward  the  bowel,  are  seen  on  the  screen  as  distally  moving 
indentations  of  the  curvatures.  Fascinating  in  interest,  sub- 
ject to  alteration  both  in  health  and  disease,  and  of  high  im- 
portance in  the  diagnosis  of  gastro-intestinal  lesions,  gastric 
peristalsis  has  been  given  much  attention. 

Looking  over  the  pubhshed  descfiptions  of  normal  peristalsis 
as  seen  by  the  roentgen-ray,  a  somewhat  disconcerting  conflict 
is  noted  between  the  various  views  expressed.  Some  of  the 
discordance  is  doubtless  due  to  a  conscious  or  unconscious  effort 
to  harmonize  the  roentgenologic  appearances  of  peristalsis  with 
certain  anatomic  conceptions  of  the  stomach,  while  other  dis- 
crepancies are  perhaps  due  to  technical  differences  in  the 
manner  of  observation. 

By  the  older  anatomists  it  was  believed  that  the  stomach 
was  partially  divided  by  a  transverse  muscular  band,  separating 
the  pyloric  portion  (antrum)  from  the  remainder  of  the  stomach. 
This  view  probably  influenced  Kaufman  and  Holzknecht^^  in 
their  description  of  peristalsis.  They  observed  the  peristaltic 
furrows  to  deepen  as  they  progressed  pylorusward,  and  reach  a 
maximum  depth  three  or  four  fingerbreadths  from  the  pylorus. 
At  this  place  the  constriction  remains  longer  as  a  tonic  and 
more  energetic  contraction  of  the  gastric  wall.  The  antral 
portion  is  completely  cut  off,  they  state,  and  a  clear  stripe  is  to 
be  seen  between  the  shadow  of  the  antrum  and  the  shadow  of 
the  corpus.  The  aDtrum  then  effaces  itself  by  a  process  of  con- 
centric contraction. 


PERISTALSIS  101 

Kaestle,  Rieder  and  Rosenthal, ^^  commenting  upon  the 
above  observation  and  additional  quotations  from  Holzknecht, 
offer  the  following  contradiction: 

"Our  investigation  shows  that  during  digestion  there  is  no  such 
division  of  the  stomach  into  two  distinct  parts,  and  that  a  strongly 
differentiated  antrum  pylori  in  the  old  acceptation  of  the  term  does 
not  exist.  As  our  tracings  show,  the  formation  of  the  new  antrum 
does  not  commence  at  the  spot  where  the  final  emptying  of  its  contents 
occurs,  and  is  therefore  not  a  mere  relaxation  of  the  contracted  walls. 
If  we  adhere  to  the  idea  of  an  antrum  pylori,  then  it  is  necessary  to 
speak  of  two  such  antra  existing  side  by  side  and  at  the  same  moment. 
We  must  speak  of  an  old  and  a  new  antrum.  As  the  old  antrum  dis- 
appears, a  new  antrum  is  developed  from  the  wall  of  the  body  of  the 
stomach.  This  new  antrum  passes  pylorus  ward,  and  ultimately 
exactly  takes  the  place  of  the  old  antrum,  whilst  another  new  antrum 
begins  to  form.  Moreover,  if  we  wish  to  adhere  to  the  term,  our  idea 
of  the  antrum  pylori  must  be  modified.  In  our  opinion,  there  is  no 
true  antrum  pylori;  any  more  than  there  is  a  sphincter  antri,  in  the 
sense  of  the  older  observers ;  what  we  see  in  the  regio  pylorica  is  an  in- 
crease in  the  energy  of  the  gastric  peristalsis  and  an  increase  in  the 
height  and  depth  of  the  wave-summits  and  depressions.  Just  as 
the  roentgen  examination  shows  no  trace  of  a  sphincter  antri,  so  anat- 
omy fails  to  show  any  trace  of  a  transverse  muscular  band,  or  anything 
in  the  nature  of  a  true  sphincter." 

The  observations  of  Kaestle,  Rieder  and  Rosenthal  were 
made  by  bioroentgenography,  a  modification  of  kinematography. 
Twelve  or  thirteen  plates  were  exposed  during  the  course  of  a 
single  peristaltic  contraction — about  twenty-two  seconds — 
shortly  after  the  ingestion  of  a  bismuth  meal.  These  plates 
show  a  continuous  progression  of  the  peristaltic  waves  to  the 
pyloric  ring.  By  superposing  tracings  of  these  plates  a  com- 
posite was  obtained  showing  graphically  the  successive  positions 
occupied  by  the  wave.  The  wave  is  shown  to  begin  at  the 
incisura  cardiaca,  whence  it  travels  pylorusward  with  slightly, 
but  steadily,  increasing  depth.  At  no  point  is  the  stomach 
completely  segmented  (Fig.  74). 

Cannon ^^  cites  the  work  of  Kaestle,  Rieder  and  Rosenthal 
as  substantiating  his  own  early  contention  that  the  pyloric  end 


102  THE   NOKMAL   STOMACH 

is  normally  not  separated  from  the  rest  of  the  stomach,  and  that 
the  waves  are  continued  over  the  vestibule.  Further  on,  how- 
ever, he  adds:  "As  digestion  proceeds,  the  constrictions  in  the 
region  of  the  vestibule  grow  still  stronger,  and  finally,  when  the 
stomach  is  almost  empty,  they  may,  as  they  come  near  the 
pylorus,  completely  divide  the  cavity.  At  all  times,  in  the 
close  neighborhood  of  the  pyloric  canal,  the  circular  and  longi- 
tudinal fibers,  both  of  which  are  hpr^trongly  developed,  prob- 


F 


w 


\      I 

/I     I         I 


Fig.   74. — Composite   diagram   showing   gastric  peristalsis.       (By   Kaestle  in   Rieder- 
Rosenthal's  Roentgenkunde.) 


ably  cooperate  to  decrease  simultaneously  in  all  directions  the 
terminal  segment  of  the  stomach." 

GroedeP*  has  noted  several  varieties  of  peristaltic  move- 
ments, including  very  shallow  waves,  deep  waves,  and  local 
contractions  of  the  gastric  wall.  The  shallow  waves  come  on 
soon  after  the  ingestion  of  food,  travel  rapidly,  and  are  hard 
to  see  with  the  naked  eye.  The  deep  wave-movements  are 
seen  on  the  greater  curvature,  begin  below  the  incisura  car- 
diaca  and  end  at  the  sphincter  antri.  The  local  contractions 
remain  for  a  longer  time,  sometimes  simulating  hour-glass 
contracion,  and  he  was  unable  to  say  whether  they  are  normal 


PERISTALSIS  103 

or  pathologic.  He  accepts  the  theory  of  a  concentric  antral 
contraction. 

Avoiding  the  terms  '^ normal"  or  ''abnormal,"  Cole^^  has 
made  a  studj^  of  "unobstructed  peristaltic  contractions," 
as  shown  by  a  series  of  roentgenograms.  He  introduces  the 
term  "gastric  cycle,"  there  being  as  many  "gastric  cycles"  as 
there  are  peristaltic  contractions  visible  at  the  same  time. 
Thus  he  notes  one,  one-and-a-half,  two,  three  and  four-cycle 
types,  and  regards  the  two  latter  as  the  more  common.  He 
holds  also  "that  the  gastric  motor  phenomenon  is  complex, 
rather  than  simplex,  as  evidenced  by  a  systole  and  diastole  of 
the  stomach  in  addition  to  the  peristaltic  contractions  passing 
pylorus  ward." 

Making  due  allowance  for  possible  slight  variations  resulting 
from  different  technics,  the  observations  of  Kaestle,  Rieder  and 
Rosenthal  offer  the  simplest  and  most  logical  explanation  of 
peristalsis,  as  we  have  seen  it  by  the  x-ray,  although  we  were 
at  one  time  inclined  to  accept  Holzknecht's  theory  of  a  concen- 
tric antral  contraction.  The  division  of  the  stomach  by  physi- 
ologists into  two  portions  with  largely  different  functions  may 
be  freely  granted,  but  the  peristaltic  phenomena  that  we  have 
observed  do  not  warrant  the  assumption  of  a  sharp  anatomical 
division  between  these  two  portions.  It  may  be  that  the  thick 
musculature  of  the  vestibule  undergoes  some  general  contrac- 
tion other  than  that  of  the  advancing  wave,  but,  if  there  is  such 
contraction,  it  is  so  slight  that  it  cannot  be  determined  and  the 
advancing  peristaltic  ring  completely  dominates  the  view. 
The  introduction  of  "gastric  cycles, "  each  with  its  "systole "  and 
"diastole,"  seems  to  us  a  needless  complication  of  the  matter, 
for  we  are  unable  to  see  any  close  similarity  between  the  action 
of  the  stomach  and  the  action  of  the  heart.  In  the  stomach  there 
is  no  general  systole  as  in  the  heart,  but  a  localized  moving 
peristaltic  contraction;  nor  is  there  a  general  diastole,  the  gastric 
contents  merely  following  up  the  advancing  wave. 

The  fact  that  the  gastric  musculature  in  addition  to  its 
circular   fibers   contains   also   longitudinal   and   oblique   fibers, 


104  THE   NORMAL   STOMACH 

justifies  the  presumption  that  these  latter  participate  in  the 
motor  functions  of  the  stomach.  But  as  it  seems  to  us,  this 
participation  is  shown  chiefly  by  a  heightening  of  tone,  with  a 
closer  embrace  of  the  gastric  contents  (peristole)  which  con- 
tinues all  through  the  period  of  peristaltic  activity,  and  is 
further  manifested  in  the  symmetrical  shrinking  of  the  stomach 
as  its  contents  are  evacuated. 

During  the  first  five  or  ten  minutea^after  filling  the  stomach 
with  the  opaque  materials  previously  described,  the  peristalsis 


Fig.   75. — Single  peristaltic  wave,  pyloric  portion. 

that  we  have  seen  most  commonly  on  the  screen  is  limited  to 
the  pyloric  portion  of  the  stomach  (Fig.  75).  First  is  noted  a 
slight  deepening  of  the  incisura  angularis.  Then  on  the  greater 
curvature,  opposite  the  incisura,  a  complementary  depression 
is  seen.  The  encircling  constriction  deepens,  then  moves 
slowly  pylorus  ward.  The  vestibule  (antrum)  is  not  completely 
segmented  and  the  vestibular  contents  escape  backward  through 
the  advancing  ring,  save  for  a  small  amount  which  may  be 


PERISTALSIS 


105 


driven  through  the  pylorus.  The  wave  continues  its  journey 
to  the  pylorus,  and,  as  it  disappears,  another  wave  is  seen  form- 
ing at  the  incisura  angularis.  Less  commonly  the  wave  begins 
in  the  pars  media  a  little  above  the  incisura  angularis,  its  de- 
pressions are  visible  on  both  curvatures,  and  it  forms  while  its 
predecessor  is  sweeping  over  the  vestibule  (Fig.  76).  Thus 
only  one  wave,  or  at  most  two  waves,  can  be  noted  as  a  rule, 
during  the  period  mentioned. 


Fig.  76, — Peristaltic  wave,  pyloric  portion;  second  wave  forming  in  body  of  stomach. 


Peristalsis  is  sometimes  a  trifle  delayed  in  its  appearance 
after  ingestion  of  the  meal.  Its  advent  may  also  be  retarded  by 
certain  nervous  states  of  the  patient,  such  as  fright  or  disgust 
for  the  meal.  It  may  sometimes  be  induced  by  massage  and 
quite  vigorous  peristalsis  may  thus  be  elicited,  but  it  dies  away 
quickly  when  the  stimulus  ceases.  Although  the  experiments 
of  Cannon  on  animals  and  the  observations  of  others  on  man 
indicate  that  peristalsis  continues  without  interruption  until 
the  stomach  is  empty,  we  have  occasionally  noticed  an  inter- 


106  THE   NORMAL   STOMACH 

mittence  during  the  early  period  after  ingestion,  activity  alter- 
nating with  absolute  or  comparative  rest. 

The  depth  of  the  wave  varies  not  only  among  individuals, 
but  also  varies  in  different  parts  of  the  stomach.  In  the  pars 
media,  on  the  greater  curvature,  the  wave-depression  is  relatively 
broad  and  shallow,  while  its  fellow  on  the  lesser  curvature  is 
'scarcely  visible  above  the  incisura  angularis.  Both  depressions 
increase  in  depth  as  they  approach  the  pars  pylorica.  From 
the  incisura  angularis  to  the  pylorus  the  waves  vary  little  in 
their  depth,  and  are  quite  similar  on  both^curvatures.  The 
energy  of  contraction  is  affected  somewhat  by  tone,  being  greater 
in  the  hypertonic  and  less  in  the  hypotonic  stomach.  It  is 
apt  to  be  increased  with  hyperacidity  and  diminished  with 
achylia  and  fatty  ingesta.  It  is  perhaps  a  trifle  more  active 
with  barium  than  with  bismuth.  Activity  is  also  increased  by 
a  prone  position  of  the  patient,  and  two  or  three  waves  may  be 
seen  at  one  time. 

Ordinarily,  waves  succeed  each  other  at  regular  intervals 
and  hence  with  regular  interspaces  as  noted  on  either  curvature. 
On  the  greater  curvature  the  depressions  are  farther  apart  than 
on  the  lesser  curvature,  the  constriction  tending  to  maintain 
a  plane  perpendicular  to  the  curving  long  axis  of  the  stomach. 

The  time  required  for  a  wave  to  run  its  course  depends  partly 
at  least  on  where  it  begins  and  the  distance  to  be  traversed. 
Twenty-two  seconds  has  been  stated  by  Kaestle  as  the  average 
time  of  transit.  His  composite  drawing  shows  the  wave 
beginning  high  up  at  the  incisura  cardiaca. 

Motility. — The  testing  of  gastric  motility  by  the  roentgeno- 
logic method  has  been  of  striking  value  in  our  own  work. 
Before  discussing  this  feature  of  the  roentgen  examination  it  may 
be  well  to  recall  some  of  the  elementary  facts  as  to  the  physiology 
of  the  gastric  motor  function.  In  this  respect  much  of  the  in- 
spiring work  of  William  Beaumont"  remains  uncontradicted 
to  this  day.  For  example  he  found  that  "the  time  required  for 
the  digestion  of  food  is  various,  depending  upon  the  quantity 
and  quality  of  the  food,  state  of  the  stomach,  etc.;  but  that 


MOTILITY  107 

the  time  ordinarily  required  for  the  disposal  of  a  moderate  meal 
of  the  fibrous  parts  of  meat,  with  bread,  etc.,  is  from  three  to 
three  and  a  half  hours."  Further,  he  drew  the  ''inference," 
as  he  expressed  it,  "that  oily  food  is  difficult  of  digestion"  and 
that  ''water,  ardent  spirits  and  most  other  fluids  are  not  affected 
by  the  gastric  juice,  but  pass  from  the  stomach  as  soon  as  they 
are  received." 

Of  the  more  recent  investigators.  Cannon,  ^^  by  his  painstak- 
ing experiments  on  animals,  has  given  us  reliable  data,  among 
which  may  be  summarized  the  following:  The  chyme  does 
not  pass  through  the  pylorus  at  the  approach  of  every  peristaltic 
wave  but  emerges  occasionally,  at  irregular  intervals,  of  from 
ten  to  eighty  seconds.  Acid  above  opens  and  acid  below  closes 
the  pylorus.  Fats  when  given  are  almost  invariably  present  in 
the  stomach  during  seven  hours'  observation.  Water  begins  to 
enter  the  intestine  almost  as  soon  as  it  enters  the  stomach. 
Carbohydrates  go  through  rapidly;  proteins  more  slowly.  When 
carbohydrates  and  proteins  are  given  one  after  another  the  early 
rate  of  evacuation  is  largely  the  same  as  that  of  the  first  food 
given.  Mixtures  of  carbohydrates  and  proteins  have  an  empty- 
ing rate  intermediate  between  that  of  carbohydrates  and  that 
of  proteins.  Fat  retards  the  exit  of  either  food-stuff  from  the 
stomach  into  the  intestine.  As  to  consistency  of  food  materials, 
there  is  a  marked  retardation  of  the  outgo  of  food  from  the 
stomach  when  hard  particles  are  present.  Considerable  amounts 
of  gas  in  the  stomach  retard  the  discharge  of  food.  Rage,  dis- 
tress, anxiety,  grief,  anger  and  violent  emotions  have  a  depressive 
effect  on  gastric  motor  activities. 

Besides  the  physiologic  variations  to  which  the  gastric  clear- 
ance time  is  subject,  it  may,  of  course,  undergo  numerous 
pathologic  alterations,  in  the  direction  either  of  an  exaggeration 
of  a  diminution  of  motility. 

It  would  seem  that  by  no  simple  test  can  sharp  and  constant 
lines  of  demarcation  be  drawn  between  hypermotility,  normal 
motility  and  hypomotility.  Nevertheless,  extreme  variations 
in  either  direction,  more  especially  toward  hypomotility,  have 


108  THE   NORMAL   STOMACH 

high  diagnostic  significance,  can  be  determined  at  least  broadly, 
and  efforts  at  such  determination  cannot  safely  be  neglected. 
The  method  in  most  common  vogue  of  testing  gastric  motility 
is  the  administration  of  a  meal  and  the  use  of  the  stomach-tube 
to  ascertain  whether  food  remnants  are  present  after  the  lapse 
of  a  certain  time.  The  following  citations  will  give  a  fair  idea 
of  this  method.  / 

Kemp^^  states  that  the  impairment  of  the  motor  power  is 
fully  as  important,  if  not  more  important,  in  many  cases  than 
damage  to  the  secretory  functions.  He  describes  various  test- 
meals  used  in  gastric  analysis  including  those  of  Riegel,*  Ewald,t 
and  Leubef  and  the  test-breakfast  of  Ewald-Boas.||  Regarding; 
the  specific  question  of  motility  he  remarks: 

''If  five  hours  after  a  test-meal,  a  small  amount  of  chyme  is  aspir- 
ated the  motor  power  is  good.  If  large  quantities  are  found  six  hours 
after  the  meal  the  motor  function  is  absolutely  (or,  if  stenosis,  relatively) 
decreased  *  *  *  Some  employ  the  test-breakfast.  Two  hours  later 
the  stomach  should  be  empty.  If  100  c.c.  or  more  are  found  at  the- 
end  of  an  hour,  or  varying  quantities  at  the  end  of  two  hours,  it  shows- 
different  degrees  of  motor  insufficiency.  The  test-meal  is  more  accu- 
rate. I  sometimes  administer  a  test-supper  and  aspirate  in  the  morn- 
ing to  test  the  motor  function,  following  immediately  with  the  test- 
breakfast  to  examine  the  secretory  function." 

Kemp  also  describes  without  comment  the  motility  tests 
with  salol  (Sievers  and  Ewald),^^  iodopin  (Heichelheim),^°  and 
oil  (Klemperer)."^ 

Bassler^^  mentions  as  of  value  the  Leube-Riegel  test-dinner,, 
consisting  of  beef-broth,  400  c.c. ;  beef,  150  gm. ;  pure  or  mashed 
potatoes,  50  gm. ;  and  a  roll  of  wheat  bread.  The  exit  of  this, 
meal  from  the  normal  stomach  should  occur  within  five  hours. 
But  he  goes  on  to  say: 

*Riegel's  test-dinner:  Meat  broth,  about  400  c.c;  beefsteak,  150  to  200  gm.;; 
mashed  potatoes,  50  gm.;  and  a  roll  (35  gm.). 

jEwald's  test-meal:  Finelj^  chopped  meat,  175  gm.;  stale  bread,  35  gm.;  and 
butter. 

tLEtJBE's  test-meal:  A  plate  of  soup,  a  beefsteak  and  a  roll. 

II  EwALD  and  Boas'  test-breakfast:  One  or  two  rolls  (35-70  gm.);  one  cup  of/ 
tea  or  water  (300-400  c.c);  given  in  the  morning  in  the  fasting  condition. 


MOTILITY  109 

"A  word  of  caution  should  here  be  given  in  assuming  the  existence 
of  pathologic  conditions  when  five  or  six  hours  afterward  small  quan- 
tities of  food  are  extracted,  for,  while  the  great  bulk  of  the  meal  is 
gone,  tarrying  remnants  of  food  may  be  present  even  in  the  perfectly 
normal  stomach  up  to  the  sixth  and  even  the  seventh  hour  after  the 
time  of  ingestion.  If  at  the  sixth,  seventh  or  eighth,  and  so  on,  hour 
of  extraction  after  the  taking  of  a  mixed  meal,  considerable  quanti- 
ties of  the  meal  constituents  are  obtained  from  a  stomach,  the  existence 
of  the  following  conditions  should  be  considered,  namely:  Pyloric 
obstruction,  states  of  atony,  a  more  or  less  low  state  of  digestive  dis- 
turbance from  degrees  of  subacute  and  chronic  gastritis  accompanied 
with  poor  gastric  function,  and  the  existence  of  neurotic  conditions 
of  a  depressing  type  affecting  the  entire  motility  of  the  organ.  Another 
form  of  examination  by  the  extraction  of  gastric  food  contents  to  diag- 
nose pyloric  obstruction  from  any  cause  (particularly  its  high  degree 
seen  in  malignancy)  should  be  mentioned.  In  this  the  generally  em- 
ployed procedure  is  to  advise  the  patient  to  eat  a  full  meal  in  the  early 
■evening,  and  then  to  wash  out  his  stomach  the  following  morning — 
about  ten  or  twelve  hours  afterward.  Should  the  patient  not  have 
vomited  during  the  night,  and  food  remnants  be  found  in  the  morning, 
bona  fide  pyloric  stenosis  can  almost  invariably  be  diagnosed." 

Bassler  states  further  that  a  simplification  of  this  method, 
which  he  can  endorse  as  of  much  value,  is  the  eating  of  several 
raisins*  in  the  evening  and  noting  if  their  skins  or  seeds  are 
obtained  in  the  morning  lavage  water.  While  in  this  test  the 
obtaining  of  vegetable  skins  is  of  much  significance,  a  negative 
result  does  not  always  mean  that  no  stenosis  exists.  A  less 
complete  degree  of  stenosis,  particularly  in  the  pyloric  region  but 
not  directly  at  the  pylorus,  may  give  positive  results  with  the 
six,  seven  or  eight-hour  extraction  of  the  mixed  meal,  but  a 
negative  finding  with  the  raisin-skin  method.  The  matter,  he 
thinks,  is  entirely  one  of  degree  of  stenosis;  the  nearer  the  stenosis 
to  the  pylorus,  the  more  accurate  are  the  results  by  both 
methods;  the  less  the  degree  of  the  stenosis,  or  the  farther 
away  from  the  pylorus  it  is  situated,  the  better  is  the  result 

*  Bassler  speaks  of  this  as  the  "Mayo  method."  In  fairness  it  should  be 
said,  however,  that  the  addition  of  raisins  to  the  Riegel  meal  is  credited  by 
CoHNHEiM  ("Diseases  of  the  Digestive  Canal,"  Edit.  2,  Philadelphia,  J.  B. 
Lippincott  &  Co.,  1911,  p.  35),  to  Boas. 


110  THE    NORMAL   STOMACH 

from  the   mixed  meal,    and   the   less   so   from   the  raisin-skin 
method. 

Einhorn-^  gives  a  fair  summarj''  of  gastro-enterologic  methods 
in  common  use  when  he  says: 

The  best  and  easiest  waj^  to  test  the  motor  function  of  the  stomach 
is  to  examine  this  organ  bj^  means  of  the  tube  and  lavage  iir'the  morn- 
ing in  the  fasting  condition  after  the  ingestion  of  a  substantial  supper 
on  the  night  previous.  Normallj^  the  stomach  is  emptj'',  and  there- 
fore when  the  organ  is  found  to  contain  a  ciuantity  of  food,  this  is  the 
best  sign  of  retarded  motion. 

Roentgenologic  Tests  of  Motility. — Since  the  first  employ- 
ment of  the  roentgen-ray  in  conjunction  with  an  opaque  meal 
for  the  diagnosis  of  gastro-intestinal  disease,  more  or  less  atten- 
tion has  been  directed  to  gastric  motility.  By  a  few  men  this 
feature  of  the  examination  is  considered  almost  indispensable; 
by  others  it  is  regarded  as  of  secondary  importance,  though 
usually  given  some  attention,  while  a  few  deem  it  of  little 
moment. 

As  might  be  expected,  an  investigation  of  the  technic  used 
by  different  roentgenologists  shows  considerable  variance. 
Wide  differences  are  noted  as  to : 

1.  The  opaque  salt  used. 

2.  The  character  of  the  vehicle. 

3.  The  proportion  of  opaque  material  to  the  medium  of  sus- 
pension. 

4.  The  total  quantity  administered. 

5.  Management  of  the  patient  with  regard  to  eating  after 
the  opaque  meal  has  been  taken. 

Mention  has  been  made  elsewhere  of  the  various  opaque 
salts  used,  including  the  subcarbonate  and  oxychloride  of  bis- 
muth, zirconium  oxide,  barium  sulphate,  etc.  So  far  as  we  are 
able  to  discover  from  the  published  observations  of  others  and 
from  our  own  experience  there  seems  to  be  little  difference  in  the 
evacuation  time  of  the  various  bismuth  salts  when  given  under 
equal  conditions;  but  the  difference  in  this  respect  between  bis- 
muth salts  and  barium  sulphate  is  marked,  the  latter  leaving 


ROENTGENOLOGIC    TESTS    OF    MOTILITY  111 

the  stomach  distinctly  earUer.  Groeders-^  figures  also  indi- 
cate that  with  barium  sulphate  the  stomach  empties  itself  much 
faster  than  with  bismuth. 

The  vehicles  employed  have  been  of  every  sort  conceivable, 
including  water,  milk,  mucilage  of  acacia,  bread  and  milk,  cereal 
porridges,  paps  and  gruels,  mashed  potatoes,  fermented  milk, 
and  mixed  meals  containing  meat.  The  proportion  of  opaque 
salt  to  suspension  medium  varies  from  10  to  50  per  cent,  of  the 
former,  and  the  total  quantity  of  the  meal  given  ranges  from  6  to 
20  ounces  or  more.  Finally,  practice  differs  as  to  permitting 
the  patient  to  follow  his  accustomed  habits  of  eating  and  drink- 
ing during  the  period  of  examination.  Often  this  important 
feature  is  not  mentioned,  yet  it  is  known  that  the  taking  of  food 
after  ingestion  of  the  opaque  meal  will  markedly  prolong  the 
evacuation  time  of  the  latter. 

It  is  quite  apparent  that  from  these  differing  technics,  differ- 
ing results  must  follow  and  this  undoubtedly  accounts  very 
largely  for  the  varying  esteem  in  which  roentgen  tests  for  motil- 
ity are  held. 

The  prototype  of  all  the  opaque  meals  now  in  use  was  that 
devised  by  Rieder,-^  and  consisted  of  50  gm.  of  bismuth  carbon- 
ate in  350  gm.  of  flour-pap.  Rieder  considered  three  to  four 
hours  as  the  normal  emptying  time,  for  this  meal.  Commonly 
half  the  meal  is  discharged  within  an  hour.  Toward  the  end 
of  digestion,  he  remarks,  there  is  a  distinct  slowing  of  emptying 
which  he  thinks  is  due  to  an  intestinal  reflex.  He  mentions  the 
experiments  of  Wulach  showing  the  emptying  time  of  carbohy- 
drate mixtures  to  be  from  two  and  one-half  to  three  and  one- 
half  hours,  albuminous  mixtures  five  or  six  hours,  and  fat  from 
seven  to  eight  and  one-half  hours.  The  roentgen  method  gives 
a  good  picture  of  gastric  motility.  But,  Rieder  adds,  in  spite 
of  the  great  excellence  of  the  roentgen  motility  test,  the  method 
formerly  used  alone  of  withdrawing  a  test-breakfast  or  test-meal 
will  firmly  retain  its  diagnostic  worth  because  it  will  show  in 
every  case  not  only  the  motility  but  also  the  secretory  function. 

Barclay^^  has  used  bismuth  carbonate  in  the  proportion  of 


112  THE    NORMAL   STOMACH 

1  to  2  or  3  of  the  excipient,  for  which  latter  he  employs  bread 
and  milk,  thoroughly  mashed  up,  or  porridge.  The  total  quan- 
tity given  varied  from  2  to  12  ounces.  With  regard  to  motility 
he  says:  ^ 

Retention  of  bismuth  food  is  the  result  of  pj'loric  obstruction  and 
Rieder  laid  it  down  that  the  whole  of  a  bismuth  meal  should  have  left 
the  stomach  within  five  hours.  For  diagnostic  purposes  this  is  a  good 
enough  guide,  but  I  never  report  definite  obstruction  unless  the  delay 
is  well  marked.  In  hospital  practice  eight  hours'  retention  is  my  stand- 
ard, but  in  the  vast  majority  of  the  cases  recorded,  some  food  was  still 
present  in  the  stomach  after  twenty-four  hours.  In  private  practice 
six  hours  is  my  standard,  but  I  always  repeat  the  observation  on  at 
least  one  occasion  to  verify  this  finding  when  the  margin  of  delay  is 
so  small. 

GroedeP"  at  first  employed  the  Rieder  carbohydrate  meal. 
An  emptying  time  beyond  four  hours  he  regarded  as  abnormal. 
Later ^^  he  began  using  barium  sulphate  250  gm.,  mixed  with 
20  gm.  each  of  maize  flour,  sugar  and  cocoa  in  400  c.c.  of  water. 
This  meal,  he  found,  emptied  normally  in  two  hours. 

Kaestle^^  considers  two  and  one-half  to  three  and  one-half 
hours  as  the  normal  emptying  time  of  a  fluid,  carbohydrate 
(mondamin),  contrast  meal  containing  zirconium  oxide  and 
weighing  400  gm.  A  stiff  mixture  of  the  same  weight  may  re- 
quire four  hours.  Slight  delay  of  evacuation  of  the  fluid  meal, 
up  to  six  hours,  he  states,  may  be  caused  by  gastric  atony, 
hyperacidity,  reflex  pylorospasm,  and  even  beginning  pyloric 
stenosis.  Residues  after  twelve  hours  or  longer  occur  only  with 
organic  pyloric  stenosis.  HjqDermotility  may  result  from  a 
gaping  pylorus  or  strong  expulsive  energ}^  (hypertonus  and 
hyperperistalsis) . 

Satterlee  and  LeWald^°  in  their  description  of  the  water- 
trap  stomach  remarked  the  occurrence  of  a  residue  from  the 
bismuth  meal  in  many  of  these  cases.  "The  water-trap  stom- 
ach," they  say,  ''might  almost  be  considered  as  a  ptosed  organ, 
with  the  first  portion  of  the  duodenum  and  the  pylorus  fixed  in 
proper  position,  giving  the  characteristic  long  pyloric  arm  and 


ROENTGENOLOGIC    TESTS    OF    MOTILITY  113 

resemblance  to  a  water  trap."     The  meal  given  consisted  of 
90  gm.  of  bismuth  subcarbonate  suspended  in  600  c.c.  of  fer- 
mented milk.     A  residue  from  this  meal,  ''long  after  the  usual 
emptying  time"  was  noted  in  50  per  cent,  of  the  cases. 
Cole^^  remarks: 

I  have  alreadj^  shown  the  fallacy  of  testing  the  gastric  motor 
efficiency  by  administering  bismuth  suspended  in  fluid  or  mixed -with 
cereal,  and  the  same  is  true  for  intestinal  motor  efficiency.  If  the  test 
is  to  be  of  value  the  stomach  and  intestines  must  be  called  on  to  evacu- 
ate such  a  meal  as  is  normally  imposed  on  them.  Therefore,  the  true 
test  of  gastro-intestinal  motor  efficiency  is  made  by  administering 
bismuth  or  barium  suspended  in  fluid,  preferably  buttermilk,  in  con- 
junction with  a  Riegel  meal  of  meat,  potatoes  and  bread.  ...  If 
the  stomach  is  high  and  of  the  cow-horn  type,  especially  if  a  condition 
of  diminished  acidity  or  achylia  exists,  evacuation  will  be  accomplished 
very  rapidly,  perhaps  in  two  hours,  whereas  many  a  stomach  present- 
ing no  organic  obstruction  requires  six  hours  for  complete  evacuation. 

Baetjer  and  Friedenwald^-  gave  a  meal  consisting  of  bismuth 
subcarbonate,  1/4  ounces;  in  an  ordinary  glass  of  water  (about 
12  ounces)  with  sufficient  mucilage  of  acacia  to  make  an  emul- 
sion. They  regard  from  three  to  four  hours  as  the  normal  empty- 
ing time  for  a  horizontal  stomach;  from  five  to  six  hours  for  a 
prolapsed  fish-hook  stomach. 

George  and  Gerber^^  call  attention  to  the  composition  of  the 
original  Rieder  meal  and  the  fact  that  other  mediums  and  much 
larger  amounts  of  the  opaque  salts  came  into  use.  They  offer 
this  comment: 

As  a  result  of  the  marked  variation  of  bismuth  meals  it  is  impossible 
to  use  the  same  functional  data  for  diagnosis ....  This  is  a  point 
which  has  not  been  appreciated  by  many  roentgenologists.  They 
have  used  various  kinds  of  meals — not  only  buttermilk,  but  malted 
milk,  plain  milk,  water,  mashed  potato,  etc.,  and  have  varied  the 
amount  of  bismuth  or  barium,  and  yet  have  attempted  to  apply  to 
their  work  the  conclusions  based  on  the  observation  of  functional  dis- 
turbances in  thousands  of  cases  done  under  the  Rieder  technic.  Ob- 
viously this  is  incorrect.     The  only  proper  course  left  for  one  who 

wishes  to  use  these  functional  data  is  to  accumulate  a  large  number  of 

•  s 


114  THE   NORMAL   STOMACH 

cases,  done  with  more  satisfactorj"  mixtures  and  check  them  up  with 
operative  results. 

In  a  paper  written  a  few-  months  prior  to  the  above,  George 
and  Gerber^*  venture  this  statement :  ''The  more  we  have  accu- 
mulated evidence  on  this  subject,  the  more  w^e  have  become  con- 
vinced that  six-hour  gastric  stasis  is  the  least  important  factor  in 
roentgen  bismuth  diagnosis."  Recently  they^^  have  reiterated 
this  opinion.  It  should  be  noted  that  with  their  technic  the 
patient  is  permitted  to  take  food  during  the  six-hour  period. 

As  a  test  of  motility  in  those  cases  in  which  the  stomach-tube 
is  contraindicated  or  refused,  Bassler^^  uses  a  mixed-meal 
method  by  w-hich  he  gives  25  gm.  of  bismuth  subcarbonate  with 
the  Riegel  meal  and  examines  by  the  roentgen  ray  six  hours  later, 
at  which  time  the  stomach  should  be  empty.  In  marked,  pyloric 
stenosis  he  has  noted  a  residue  at  twelve  hours,  or  much  later, 
even  to  five  days.  How'ever,  in  a  subsequent  publication, 
Bassler"  has  this  to  say: 

In  the  study  of  motility  and  exit  from  the  stomach  in  203  cases  of 
distinct  gastroptosia,  in  which  hourly  roentgen-ray  observations  were 
made,  the  conclusion  was  plain  that  the  roentgen-ray  method  of  diag- 
nosing stasis  in  the  stomach  is  not  as  practical  as  the  test-meal  method. 
One  hundred  and  twenty-six  of  these  cases  examined  by  the  bismuth- 
roentgen-ray  method  showed  delay  of  exit  of  six  hours  or  more,  while 
only  31  showed  the  delay  by  the  test-meal  method.  .  .  .  Instances 
were  encountered  in  which  bismuth  was  present  in  the  stomach  as 
late  as  eighteen  hours  after  ingestion,  while  the  stomach  on  a  mixed 
meal  was  empty  in  fom'  and  one-half  hours.  ...  It  is  apparent, 
whatever  has  been  advanced  to  the  contrary,  that  the  method  of  ex- 
amination by  food  extraction  is  decidedly  more  to  be  depended  on  in 
gaining  an  idea  of  exit  from  the  stomach  than  is  the  bismuth-roentgen- 
ray  method,  for  it  was  strongly  suggested  that  foods  pass  from  the 
stomach  in  decidedly  less  time  than  will  bismuth  or  any  other  form  of 
metal  salts  used  to  throw  a  shadow,  probably  because  of  the  pulverized 
salts  adhering  to  the  mucosa. 

The  most  faithful  advocate  of  the  roentgen  motility  test  is 
Haudek,^^and  tohimw^e  are  indebted  for  the  double-meal  method 
of  examination,  the  establishment  of  the  six-xxour  limit  and  a 


ROENTGENOLOGIC    TESTS    OF   MOTILITY  115 

vast  deal  of  information  concerning  the  significance  of  disordered 
motility  as  shown  by  the  roentgen  ray.  The  rather  chaotic 
application  of  the  roentgen  examination  for  motility  led  Haudek, 
in  1909,  to  establish  his  double-meal  method,  partly  with  the 
view  of  saving  time  and  partly  to  make  the  test  more  precise. 
Accordingly,  he  began  the  administration  of  a  Rieder  meal  in  the 
morning,  and  examined  the  patient  six  hours  later,  at  which  time 
a  second  Rieder  meal  was  given  to  complete  the  examination. 
The  selection  by  Haudek  of  six  hours  as  the  division  line  between 
normal  and  delayed  emptying  was  explained  by  him  on  the 
ground  that  while  the  normal  stomach  will  drive  out  a  Rieder 
meal  in  about  three  hours,  as  an  average,  delay  to  -five  or  six 
hours  might  result  from  physiologic  causes.  He  cited  as  exam- 
ples the  influence  of  rest  and  movement,  right  and  left-side  posi- 
tions, psychic  factors,  eating  or  drinking  after  taking  the  meal, 
and  sedimentation  of  the  opaque  salt.  Even  after  six  hours  or 
longer,  minute  residues  might  sometimes  be  found  in  normal 
stomachs,  and  he  accordingly  ignored  mere  traces.  Small  resi- 
dues, up  to  a  quarter  of  the  meal,  he  deemed,  could  be  due  not 
only  to  organic  pathologic  changes  but  also  to  hypomotility  from 
atony,  hyperacidity,  or  long  hubhohe,  that  is,  a  long,  vertical 
pars  pylorica.  Larger  residues  could  be  almost  certainly  ascribed 
to  pyloric  obstruction  by  organic  stenosis  or  spasm  from  ulcer. 
He  also  pointed  out  that  the  test  did  not  rest  alone  on  the  pres- 
ence or  absence  of  a  residue,  but  that  the  position  of  the  ''head" 
of  the  six-hour  meal  gave  gross  information  as  to  motility. 
Normally  at  or  near  the  cecum,  the  ''head"  would  be  advanced 
far  into  the  large  intestine  by  hypermotility  or  held  back  in  the 
small  intestine  by  hypomotility.  Further,  on  giving  the  second 
meal,  there  could  also  be  taken  into  consideration  the  tonus  of 
the  stomach,  its  peristalsis,  the  freedom  of  passage  through  the 
pylorus,  the  hubhohe,  and  thus  the  total  picture  would  enable  an 
estimation  of  "the  great  'X'  of  motility,  the  functioning  of  the 
pylorus." 

An  experience  of  years  with  thousands  of  cases  has  increased 
Haudek's  confidence  in  the  method.     In  a  recent  article,  he^®; 


116  THE   NORMAL   STOMACH 

goes  SO  far  as  to  say  that  the  roentgen  determination  of  the  ex- 
peUing  forces  of  the  stomach  gives  better  results  than  the  older 
methods,  and  that  it  is  not  only  exact  and  reliable  but  also  very 
simple.  He  shows  that  while  the  clinical  examination  cannot 
determine  whether  the  increase  or  decrease  of  motility  is  due  to 
a  change  of  the  expelling  power  or  of  the  resistance,  the  roentgen 
examination  can  be  much  more  decisive.  While  he  had  pre- 
viously considered  atony  to  be  an  occasional  cause  of  six-hour 
retention  he  now  believes  that  atony,  under  otherwise  normal 
conditions,  causes  only  a  slight  lengthening  of  evacuation  time, 
usually  below  six  hours.  The  most  important  factor  for  the 
evacuation  of  the  stomach  is  the  condition  of  the  pylorus. 
Lessening  of  resistance  produces  the  picture  of  pyloric  insuffi- 
ciency; an  increase  leads  to  the  highest  degrees  of  stagnation. 

For  more  than  four  years  past  our  work  has  been  based  on  the 
double-meal  method  of  Haudek,  and  we  can  unreservedly  endorse 
his  claims.  .  For  various  reasons  w^e  have  found  it  advisable 
to  modify  his  technic  in  some  particulars,  but  have  retained  the 
six-hour  limit  and  adhered  rather  closely  to  his  general  princi- 
ples. A  cereal  porridge  instead  of  a  pap  for  the  six-hour  meal  is 
employed  and  barium  sulphate  substituted  for  bismuth  salts. 
(For  detailed  technic  refer  again  to  page  75.)  Since  barium 
leaves  the  stomach  earlier  than  bismuth  we  believe  that  a  six- 
hour  retention  of  barium  is  even  more  significant  than  one  of 
bismuth.  Until  the  beginning  of  1914  patients  were  required 
to  take  castor  oil  in  the  evening  previous  to  the  day  of  examina- 
tion, but  this  has  been  abandoned  as  unnecessary.  The  obser- 
vations of  Hayes^°  show  that  purgation  results  in  a  heightening 
of  gastro-intestinal  motility  for  a  day  or  two.  A  comparison 
of  our  observations  since  1914  with  those  made  previously,  in- 
dicates that  this  increase  does  occur,  but  that  it  does  not  mate- 
rially affect  the  six-hour  test. 

With  the  stomach  empty  at  the  end  of  six  hours  and  the  head 
of  the  motor  meal  anywhere  from  the  cecum  to  the  hepatic  flex- 
ure the  gastric  motility  is  considered  normal,  at  least  so  far  as 
the  net  result  is  concerned.     It  does  not  follow  that  this  finding 


REFERENCES  117 

absolutely  excludes  any  disturbance  of  either  the  active  or  pas- 
sive factors  of  motility,  since  a  diminution  of  one  may  be  offset 
by  an  exaggeration  of  the  other.  For  example,  a  somewhat 
stenotic  pylorus  or  duodenum  may  be  balanced  by  vigorous 
gastric  peristalsis,  or  an  achylia;  or  a  so-called  atonic  stomach 
with  weak  peristalsis  may  evacuate  its  contents  through  an  un- 
usually patent  pylorus  in  average  time.  Hence  a  stomach  that 
is  empty  at  six  hours,  with  the  motor  meal  at  or  not  far  beyond 
the  cecum,  is,  strictly  speaking,  normal  as  to  motility  only  on 
condition  that  other  elements  are  normal  also,  that  is,  acidity, 
peristalsis,  tonus  and  pyloric  functioning.  If  any  of  the  latter 
are  definitely  abnormal,  the  presumption  is  that  one  abnormality 
is  compensated  by  some  other,  and  an  analysis  of  the  complica- 
tion may  promote  diagnostic  nicety.  With  our  present  limita- 
tions, however,  a  calculation  of  this  sort  could  easily  lead  to 
error  by  its  intricacy.  Likewise,  between  the  average  emptying 
time  of  say  three  hours  and  the  arbitrary  limit  of  six  hours 
allowed  for  presumptively  normal  evacuation,  is  a  rather  wide 
zone  for  the  play  of  physiologic  and  occasionally  pathologic, 
factors  causing  hypomotility.  It  was  precisely  to  make  liberal 
allowance  for  these  that  Haudek  drew  his  line  at  six  hours,  and 
for  this  reason  we  have  adhered  to  that  line,  though  our  meal 
probably  leaves  the  stomach  earlier  than  Haudek's.  If  there  is 
error  it  is,  at  all  events,  on  the  side  of  safety. 

A  degree  of  hypermotility,  as  evinced  by  advancement  of  the 
meal  beyond  the  hepatic  flexure  and  by  rapid  discharge  of  the 
second  meal  through  the  pylorus,  not  rarely  has  a  physiologic 
explanation,  as,  for  example,  a  hypertonic,  steer-horn  stomach. 
But  marked  hypermotility  should  stimulate  a  search  for  possible 
pathologic  causes. 

REFERENCES 

1.  Stiller,  B.:  "Die  asthenische  Konstitutions-Krankheit."     Stutt- 

gart, F.  Enke,  1907,  1-225. 

2.  Stiller,  B.:  "Kritische  Glossen  eines  Klinikers  zur  Radiologie 

des  Magens."     Berlin,  S.  Karger,  1910,  1-28. 

3.  HoLZKNECHT,  G. :  ''Der   normale   Magen  nach  Form,  Lage  und 


118  THE   NORMAL   STOMACH 

Grosze."     Mitteilungen  aus  dem  Lab.  jiir  Rad.  Diag.,  1906,  i, 
72-84. 

4.  Cannon,  W.  B.:  ''Mechanical  Factors  of  Digestion."     New  York, 

Longmans,  Green  &  Co.,  1911,  47-48. 

5.  ScHLESiNGER,  E. :  "Die  Grundformen  des  normalen  und  patholo- 

gischen  Magens  und  ihre  Entstehung."     Berl.  klin.  Wchnschr., 
1910,  xlvii,  1977-1981. 

6.  Barclay,  A.  E.:  "The  Stomach  and  Esophagus."     Xew  York, 

Macmillan  Co.,  1915,  59. 

7.  EwALD,    C.    A.:  "Diseases   of   the   Stomach."     New   York,    D. 

Appleton  &  Co.,  1902,  91-92. 

8.  Gray,  H.:  "Anatomy,  Descriptive  and  SurgicaL"     Philadelphia, 

Lea  Bros.  &  Co.,  1905,  1273. 

9.  Kaestle,  K.:  "Versuch  einer  neuen  Methode  zur  Priifung  der 

Verweildauer  von  Flussigkeiten  im  Magen."     Muench.  Med. 
Wchnschr.,  1910,  Ivii,  1837-1838. 

10.  ScHWARz,  G. :  "tJber  Salzsaure  Probe  ohne  Magenschlauch."    Ver- 

handlungen  der  Deut.  Rontgen-Gesellschaft,  iii,  II.  Sitzung,  68-69. 

11.  Kaufman,  R.  and  Holzknecht,  G.:  "Die   Peristaltik  am  An- 

trum  pylori   des   Menschen."     Mitteilungen  aus  dem  Lah.  fUr 
Rad.  Diag.  und  Ther.,  1906,  i,  66-71. 

12.  Kaestle,  K.,  Rieder,  H.  and  Rosenthal,  J.:  "The  Bioroentgen- 

ography  of  the  Internal  Organs."     Arch.  Roent.  Ray,  1910-11, 
XV,  3-12. 
Kaestle,  K.:  "Lehrbuch  der  Roentgenkunde,"  by  Rieder-Rosen- 
thal,  Leipzig,  Barth,  1913,  i,  504. 
L3.  Cannon,  W.  B.:  "The  Mechanical  Factors  of  Digestion."     New 
York,  Longmans,  Green  &  Co.,  1911,  53. 

14.  Groedel,  F.  M.  :  "Atlas  und  Grundriss  der  Roentgen  Diagnostik." 

Munich,  J.  F.  Lehmann,  1909,  193-194. 

15.  Cole,  L.  G.:  "The  Complex  Motor  Phenomena  of  Various  Types 

of  Unobstructed  Gastric  Peristalsis."     Arch.  Roent.  Ray,  1911- 
1912,  xvi,  242-247. 

16.  In  the  "Life  and  Letters  of  Dr.  William  Beaumont,"  by  J.  S. 

Myer,  St.  Louis,  C.  V.  Mosby  Co.,  1912,  201. 

17.  Cannon,  W.  B.:  "The  Mechanical  Factors  of  Digestion."     New 

York,  Longmans,  Green  &  Co.,  1912,  84. 

18.  Kemp,  R.  C:  "Diseases  of  the  Stomach  and  Intestines."     Phila- 

delphia, W.  B.  Saunders  Co.,  1911,  122. 

19.  SiEVERs,  R.  and  Ewald,  C.  A.:  "Zur  Pathologic  und  Therapie 

der  Magenektasien."     Therap.  Monatsh.,  1887,  i,  289-291. 

20.  Heichelheim,  S.:  Ztschr.  f.  klin.  Med.,  1900,  xli,  321-331. 


REFERENCES  119 

21.  Klemperer,  G.:  "Uber  die  Motorische  Tiitigkeit  des  Menschlichen 

:\Iagens."     Deutsch.  med.  Wchnschr.,  1888,  xiv,  962-966. 

22.  Bassler,  a.:  "Diseases  of  the  Stomach  and  Upper  AHmentary 

Tract."     Philadelphia,  F.  A.  Davis  Co.,  1913,  158. 

23.  EiNHORN,  M.:  "Diseases  of  the  Stomach."     New  York,  Wilham 

Wood  &  Co.,  1911,  119. 

24.  Groedel,  F.  M.  :  "The  Influence  of  Various  Contrast  Substances  on 

the  Motility  of  the   Intestinal    Canal."      Aixh.    Roent.    Ray, 
April,  1913,  420. 

25.  RiEDER,  H. :  "Das  Roentgen- Yerfahren  im  Dienste  der  Pathologie 

und  Therapie  des  Magen-Darm-Kanales,"  Yerhandl.  cl.  xxix, 
Deutsch.    Kong.  f.    Lit.   Med.,    J.    F.    Bergmann,  Wiesbaden, 

1912,  22. 

26.  Barclay,  A.  E.:  "The  Stomach  and  Esophagus."     New  York, 

Macmillan  Co.,  1913,  9,  36. 

27.  Groedel,  F.  M.:  "Atlas  und  Grundriss  der  Roentgendiagnostik." 

IMunich,  J.  F.  Lehmann,  1909,  176,  198. 

28.  Groedel,  F.  yi.:  "The  Influence  of  Various  Contrast  Substances 

on  the  Motility  of  the  Intestinal  Canal."     Arch.  Roent.  Ray, 

1913,  xvii,  420. 

29.  Kaestle,    K.  :  "Lehrbuch    der    Roentgenkunde    (Rieder-Rosen- 

thal)."     Leipzig,  J.  A.  Barth,  1913,  i,  531. 

30.  Satterlee,  G.  R.  and  LeWald,  L.  T.:  "One  Hundred  Cases  of 

Water-trap  Stomach."     Jour.  A.  M.  A.,  1913,  Ixi,  1340-1344. 

31.  Cole,  L.  G.:  "Relation  of  Lesions  of  the  Small  Intestine  to  Dis- 

orders of  the  Stomach  and  Cap  as    Observed    Roentgenolog- 
ically."     Amer.  Jour.  Med.  Sci.,  1914,  cxlviii,  92-118. 

32.  Baetjer,  F.  H.  and  Friedenwald,  J.:  "On  the  Diagnosis  of  In- 

complete Forms  of  Pyloric  Stenosis  by  Means  of  the  Roentgen 
Ray."     Boston  Med.  and  Surg.  Jour.,  1914,  clxxi,  261-264. 

33.  George,  A.  W.  and  Gerber,  I.:  "The  Roentgen  Diagnosis  of 

Duodenal  Ulcer."     Surg.,  Gynec.  and  Obstet.,  1914,  xix,  395-403. 

34.  George,  A.  W.  and  Gerber,  I. :  "  The  Practical  Apphcation  of  the 

Roentgen  Method  to  Gastric  and  Duodenal  Diagnosis."     Jour. 
A.M.  A.,  1914,  Ixii,  1071-1073. 

35.  George,  A.  W.  and  Gerber,  I. :  "  Observations  from  the  Study  of 

a    Thousand  Gastro-intestinal  Cases."     Amer.    Jour.    Roent- 
genology, 1915,  ii,  592-600. 

36.  Bassler,  a.:  "Diseases  of  the  Stomach  and  Upper  Alimentary 

Tract."     Philadelphia,  F.  A.  Davis  Co.,  1913,  213. 

37.  Bassler,  A.:  "Some  Recent  Conclusions  on  Abdominal  Roentgen 

Ray  Work."     Jour.  A.  M.  A.,  1913,  Ixi,  2217-2218. 


120  THE   NORMAL   STOMACH 

38.  Hal-dek,  M.:  ''Die  Technik  und  Bedeutung  der  Radiologischen 

]Motilitatsprufung."     Verhandl.  d.  xxix,  Deutsch.  Kong.  f.  Int. 
Med.,  J.  F.  Bergmann,  Wiesbaden,  1912,  143. 

39.  Haudek,  M.:  "tJber  die  Radiologische  Priifung  der  Magenmo- 

tilitat  und  Ihre  Resultate."     Fortschr.  a.  d.  Geb.  d.  Roentgen- 
strahlen,  1914,  xxi,  472. 

40.  HayeSj  M.  R.  J.:  "Roentgen  Rays  in  the  Diagnosis  of  Abnor- 

malities of  the  Intestinal  Tract."     Cliii.  Jour.,  1914,  xliii,  529. 
Abstr.  Surg.,  Gynec.  and  Ohstet.,  1915,  xx,  138. 


CHAPTER  VII 
THE  ABNORMAL  STOMACH 

Form  Variations. — Other  things  being  equal,  the  general 
form  of  the  stomach  should  correspond  to  the  habitus  of  its 
possessor,  and  an  inharmonious  combination  demands  explana- 
tion. Thus,  the  steer-horn  form  of  stomach,  which  is  some- 
times seen  normally  in  the  broad  habitus,  is  to  be  regarded  with 
suspicion  if  seen  in  association  with  the  habitus  enteroptoticus^ 
and  the  possibility  of  a  carcinoma  or  other  lesion  should  be  in- 
vestigated. On  the  other  hand,  the  occurrence  of  a  fish-hook 
stomach  in  a  person  of  the  broad  habitus  is  not  necessarily  sig- 
nificant, unless  the  stomach  be  also  hypotonic  and  elongated. 

The  form  of  the  stomach  has  some  slight  indicative  value  in 
predicating  the  nature  of  a  lesion  which  may  possibly  exist.  For 
example,  ulcer  is  rarely  found  in  a  steer-horn  stomach;  by  far 
the  larger  number  of  ulcers  that  we  have  seen  occurred  in  the 
fish-hook  type.  In  fact,  the  steer-horn  type  of  stomach,  which 
is  itself  infrequent,  rather  seldom  show^s  lesions  of  any  sort. 
The  apparent  steer-horn  occasionally  seen  in  advanced  scirrhous 
carcinoma  is,  of  course,  a  result  of  the  pathologic  process.  The 
hook-form  is  often  preserved  in  medullary  carcinoma  of  the 
stomach.  A  snail-form  of  the  stomach,  with  acute  flexion  of 
the  pyloric  end  toward  the  lesser  curvature  is  found  occasionally 
in  gastric  ulcer. 

Marked  distortion  and  deformity  of  the  stomach  may  occur 
with  gastric  carcinoma  and  tumors  of  all  sorts,  syphilis,  ulcer, 
spasm,  extrinsic  tumors,  ascites,  or  increased  intra-abdominal 
tension  from  any  cause,  including  voluntary  contraction  of  the 
abdominal  muscles. 

Hour-glass  Stomach. — Some  confusion  has  arisen  from  a 
rather  indiscriminate  use  of  this  term.     Broadly  speaking,  it 

121 


122 


THE   ABNORMAL   STOMACH 


applies  to  anj^  stomach  which  is  constricted  or  segmented  so  as 
to  form  two,  and  exceptionally  three  or  more,  distinct  loculi, 
even  temporarily.  To  the  surgeon  the  word  generally  signifies 
an  organic  and  permanent  biloculation,  and,  failing  to  find  such 
a  condition  at  operation,  he  regards  the  diagnosis  of  hour-glass 
stomach  as  erroneous,  although  the  roentgen  findings  may  have 
been  quite  definite. 

Organic  hour-glass  stomach  may  result  from  ulcer,  carcino- 
matous, syphilitic  or  other  tumors  of  the  gastric  wall,  or,  rarely, 


Fig. 


-Perforating   gastric  ulcer  a.     Hour-glass   constriction   at   b. 


from  adhesion-bands.  A  few  rare  cases  have  been  reported  in 
which  the  condition  was  a  congenital  deformity  (Adami  and 
Nicholls^).  Spasmodic  hour-glass  stomach,  solely  the  result  of 
spasm,  may  have  as  its  antecedent  cause  a  lesion  within  the 
stomach  or  an  extrinsic  condition. 

The  organic  hour-glass  seen  sometimes  in  association  with 
gastric  ulcer,  usually  results  from  the  perforating  type  and  is 
due  not  merely  to  spasm  of  the  circular  muscle-fibers  but  to  in- 
filtration and  adhesions  (Fig.  77).     As  a  rule,  the  canal  joining 


HOUE-GLASS    STOMACH 


123 


the  two  loculi  is  short  and  near  the  lesser  curvature.  Thus  the 
stomach  has  some  resemblance  to  a  capital  B.  With  syphilitic 
ulcer,  hour-glass  contraction  seems  to  be  common. 

The  organic  hour-glass  of  gastric  carcinoma,  syphilis  and 
other  tumor-producing  lesions  caused  by  the  projection  of  the 
tumor-mass  into  the  gastric  lumen  usually  shows  characteristic 
irregularity  and  shading  of  outline.  The  canal  uniting  the  two 
segments  is  usually  longer  than  that  seen  wdth  the  hour-glass  of 
ulcer.     Sometimes,  and  especially  in  carcinoma,  the  canal  is 


Fig.   78. — Organic  hour-glass  at  a.     Cancer  of  the  stomach. 


centrally  placed,  so  that  the  stomach  has  the  form  of  a  script  X 
(Fig.  78). 

The  hour-glass  form  due  to  spasm  is  frequently  of  the  B-type, 
resulting  from  a  deep,  incisure-like  indentation  of  the  greater 
curvature.  This  contraction  may  be  caused  by  an  ulcer  or  its 
scar;  or  it  may  occur  in  association  with  neuroses  or  conditions 
outside  the  stomach  such  as  lesions  of  the  gall-bladder,  duodenal 
ulcer  or  appefidicitis.     It  may  also  occur  independently  of  any 


124  THE   ABNORMAL   STOMACH 

discoverable  lesion.  Sharpness  of  the  constricted  outline  is 
fairly  constant  in  spastic  hour-glass. 

An  extremely  hypotonic,  elongated  stomach,  with  approxi- 
mated vertical  walls,  may  superficially  simulate  an  hour-glass, 
but  upon  pushing  the  barium  upward  the  seeming  constriction 
disappears.  Tumors  outside  the  stomach  may  so  deeply  indent 
the  gastric  contour  as  to  give  the  stomach  an  hour-glass  form; 
palpatory"  manipulation  will  usually  show  the  condition.  Strong 
retraction  of  the  abdomen  or  the  dorsal  position  may  result  in 
more  or  less  biloculation  of  the  stomach  by  the  vertebral  ridge. 
Likewise,  compression  of  the  patient's  abdomen  against  the  plate 
while  radiographing  either  in  the  standing  or  prone  position  may 
cause  a  similar  segmentation.  It  is  to  be  assumed  that  the  ob- 
server will  recognize  a  peristaltic  constriction  and  will  not  con- 
found it  with  hour-glass  constriction.  The  shadow  of  a  large 
mammary  gland  merging  with  the  gastric  outline  may  appear 
somewhat  like  an  hour-glass  deformity. 

Differentiation  of  an  hour-glass  produced  by  a  gastric  lesion, 
from  a  spastic  hour-glass  due  to  conditions  outside  the  stomach, 
is  often  possible.  The  purely  reflex  spasmodic  hour-glass  may 
often  be  relaxed  by  energetic  manipulation  during  the  screen- 
examination.  If,  in  spite  of  this,  it  persists,  belladonna  given  to 
physiologic  effect  (see  page  166)  will  nearly  always  relax  it. 
Organic  hour-glass  and  the  spastic  hour-glass  of  ulcer  constantly 
withstand  these  measures. 

Changes  of  Contour. — Irregularities  of  the  gastric  outline 
are  of  the  highest  importance  in  roentgenologic  diagnosis. 
These  alterations  consist  either  of  localized  additions  to  or  sub- 
tractions from  the  visualized  gastric  lumen. 

As  examples  of  the  former  we  have  the  niche  of  penetrating 
ulcer  and  the  accessory  pocket  of  perforating  ulcer.  The  niche 
represents  the  crater  of  the  ulcer,  varies  in  size  from  that  of  a  pea 
to  -that  of  a  cherrj^  or  larger,  and  shows  as  a  direct  extension  of 
the  lumenal  shadow  (Fig.  79).  It  is  more  commonly  located  on 
or  near  the  lesser  curvature  of  the  pars  media,  but  may  be  found 
on  the  anterior  wall,  posterior  wall,  or  greater  cufvature.     The 


CHANGES    OF    CONTOUR 


125 


Fig.  79. — Penetrating  ulcer.     Niche  at  a. 


Fig.  80. — Accessory  pocket  at  a,  due  to  perforating  ulcer. 


126  THE   ABNORMAL   STOMACH 

accessory  pocket  is  an  excavation  produced  by  the  extension  of  a 
perforating  gastric  ulcer  into  adjacent  tissue,  usually  the  liver 
or  pancreas  (Fig.  80) .  It  shows  as  a  shadow  the  size  of  a  filbert 
or  Walnut  outside  but  near  the  gastric  lumen.  Its  channel  of 
communication  with  the  latter  is  not  easilj^  demonstrable.  Its 
own  contour  may  be  symmetrically  rounded  or  irregular.  Por- 
tions of  the  opaque  meal  in  the  bowel  adjacent  to  the  stomach 
may  occasionally  simulate  a  niche  or  pocket,  but  a  change  in  the 
position  of  the  patient  and  abdominal  manipulation  -will  usually 
show  the  true  condition.  The  bulge  between  two  peristaltic 
waA'e  depressions  close  to  each  other  on  the  lesser  curvature  has 
a  superficial  resemblance  to  a  niche  except  that  it  advances  with 
the  progress  of  the  waves,  while  a  niche  remains  stationary. 

Localized  subtractions  from  the  gastric  outhne,  known  as 
filling-defects,  may  be  actual  and  permanent  if  due  to  lesions  in- 
volving the  gastric  wall,  or  apparent  and  non-permanent  if  due 
to  extraneous  conditions.  Actual  fiUing-defects  are  noted  in 
carcinoma  (Fig.  81),  s^TDhihs,  benign  tumor,  varicosities  and 
adhesions.  Apparent  filhng-defects  may  result  fromfas  or  feces 
in  the  adjacent  bowel  (Fig.  82),  extrinsic  tumors  (Fig.  83), 
spasm  of  the  gastric  musculature,  extreme  intra-abdominal  pres- 
sure,, fluid  pent  up  in  the  pyloric  end  of  the  stomach,  food  rem- 
nants or  foreign  bodies  in  the  stomach,  fault}^  opaque  mixtures 
separating  irregularly,  or  the  pressure  of  a  kyphotic  or  lordotic 
spine.  On  the  plate  the  displacement  of  the  visuahzing  meal, 
resulting  from  compression  of  the  stomach  against  the  spine 
(Fig.  84),  is  likely  to  be  misinterpreted  by  the  novice  as  an  actual 
filhng-defect.  Tests  of  the  genuineness  of  a  filUng-defect  are 
its  persistence  under  all  conditions  during  the  screen-exami- 
nation, its  unaltered  position  and  configuration  after  massage, 
its  constancy  upon  all  plates  and  at  successive  examinations, 
and,  as  a  differential  point  from  spasm,  its  resistance  to  antispas- 
modics. 

The  incisura,  often  a  relatively  deep,  narrow,  finger-shaped, 
indentation,  sometimes  a  small  angular  notch,  almost  always 
seated  on  the  greater  curvature,  is  seen  occasionally  in  ulcer,  as  a 


CHANGES    OF    CONTOUE 


127 


Fig.  81. — Extensive    filling    defects,   in    the    body   of   stomach,    due   to   cancer   at  a. 


Fig.  82.- 


-Apparent  filling  defect  along  the  greater  curvature,  due  to  gas 
in  the  colon  at  a. 


128 


THE   ABNORMAL   STOMACH 


Fig.   83. — Filling  defect  in  vertical  portion  of  the  stomach,   produced  by  an  extrinsic 

tumor,  at  a 


Fig.  84. — Apparent  filling  defect,   caiisnl  1>,\    iiiessure   of  stomach  against  the  spine, 

seen  at  a. 


ALTERATIONS    OF   TONE' 


129 


result  of  spastic  contraction  of  the  circular  muscle-fibers  in  the 
plane  of  the  ulcer  (Fig..  85).  Similar  incisurse  may  be  pro- 
duced by  an  adhesion-band,  or  by  reflex  spasm  from  conditions 
outside  the  stomach.  The  wide,  relatively  shallow,  spastic  in- 
drawing  of  the  curvature  seen  now  and  then  opposite  a  carcin- 
oma is  sometimes  spoken  of  as  a  wide  incisura.  The  incisura  of 
gastric  ulcer  occupies  a  constant  situation  and  is  usually  per- 
sistent, although  some  observers  have  claimed  that  shallow  ul- 


FiG.   85. — Penetrating  ulcer  at  a.     Incisura  at  h. 

cers  or  erosions  may  give  rise  to  intermittent  incisurse.  Two 
ulcers  in  different  planes  may  give  rise  to  a  double  incisura. 
The  incisura  arising  from  an  extrinsic  reflex  is  most  often  of  an 
exaggerated  type,  being  deeper  and  wider  than  the  incisura  of 
ulcer.  Frequently  it  is  associated  with  a  tumultuous,  irregular 
peristalsis,  and  travels  like  a  peristaltic  wave.  Again,  it  may 
persist  at  one  spot,  or  recur  there  intermittently. 

Alterations  of  Tone. — The  hypertonic  stomach,  though  found 
in  normal  persons,  is  also  a  common  accompaniment  of  non- 


130 


THE   ABNORMAL   STOMACH 


Fig.   86. — Hj-pertonic  stomach. 


Fig.  87. — Hypotonic  stomach. 


ALTEEED    POSITION  131 

obstructing  duodenal  ulcer,  and  it  may  result  reflexly  from  other 
irritated  foci  outside  the  stomach  (Fig.  86).  The  small  shrunken 
stomach  of  scirrhous  carcinoma  or  fibromatosis  is  only  appar- 
ently hypertonic. 

The  hypotonic  stomach  is  not  rarely  observed  without  any 
lesion,  especially  in  asthenic  persons  and  those  with  relaxed 
abdominal  walls  (see  '^ Normal  Stomach,  Tonus").  Loss  of  tone 
and  dilatation  of  various  degrees  may  occur  as  a  sequence  of 
long-continued  spastic  or  organic  obstruction  at  or  near  the 
pylorus  from  gastric  ulcer,  carcinoma,  benign  tumors,  lesions  of 
the  gall-bladder,  obstructive  duodenal  ulcer,  etc.  (Fig.  87). 

Altered  Position. — The  cardiac  end  of  the  stomach  being 
fixed  and  the  pyloric  end  being  little  less  so,  we  are  concerned  in 
most  instances  with  displacement  of  the  body  of  the  stomach, 
more  especialy  the  lower  pole,  which  may  be  dislocated  in  any 
direction.  Displacement  of  the  lower  pole  upward  and  to  the 
left  may  be  produced  by  perforating  gastric  ulcer,  extrinsic 
tumors,  ascites,  pregnancy,  heightened  abdominal  tension,  or 
spasm;  downward  in  hypotonus  from  any  cause,  dilatation,  or 
ptosis.  Lateral  displacement,  to  either  side,  by  gas  in  the  in- 
testine or  by  tumors  outside  the  stomach,  is  not  uncommon. 

Rarely  the  fundus  itself  may  be  displaced  upward  in  dia- 
phragmatic hernia  or  eventration,  and  Schlesinger-  holds  that  it 
may  participate  to  some  extent  in  the  downward  displacement 
of  gastroptosis. 

The  pylorus,  tethered  by  the  duodenojejunal  ligament,  is 
not  easily  susceptible  to  any  considerable  dislocation  in  an  indi- 
vidual case.  But  its  position  varies  markedly  in  different  indi- 
viduals, in  correspondence  with  the  form  of  the  stomach  and 
the  habitus  (see  "Normal  Stomach").  Sometimes,  also,  its 
position  is  not  in  harmony  with  the  general  position  of  the  stom- 
ach, and  a  degree  of  displacement  may  be  obvious.  Thus  with 
the  curled-up,  snail-form  of  stomach,  seen  rarely  in  gastric  ulcer, 
the  pylorus  may  lie  well  to  the  left  of  the  median  hne.  Excep- 
tionally, the  pyloric  end  may  be  drawn  upward  and  to  the  right 
by  pericholecystic  adhesions.     While  we  have  observed  broad 


132  THE   ABNOEMAL   STOMACH 

variations  as  to  the  height  of  the  pylorus  in  persons  without  any 
gastric  lesion,  GroedeP  considers  pyloroptosis  as  a  sign  of  gas- 
troptosis,  and  with  the  ptosis  is  associated  a  greater  mobility  of 
the  pylorus. 

Occasionally  there  is  noted  an  apparent  torsion  of  the  fish- 
hook stomach  to  the  right  side  on  its  long  axis,  so  that  the  cor- 
pus lies  in  front  of  the  pylorus;  this  displacement  seems  most 
often  to  be  produced  by  causes  outside  the  stomach,  and  is  with- 
out other  import.  Transposition  of  the  stomach,  as  a  feature 
of  situs  inversus,  deserves  only  casual  mention. 

Alteration  of  Size. — Diminished  size  (capacity),  real  or  ap- 
parent, may  be  due  to  hypertonus,  increased  intra-abdominal 
tension,  carcinoma,  syphilis,  benign  tumors,  spasm,  starvation, 
esophageal  obstruction,  operative  resection,  or  gastro-enteros- 
tomy. 

Increased  size  may  be  the  result  of  hypotonus,  functional 
atony,  or  dilatation  consequent  upon  obstruction  at  or  near  the 
pylorus  (gastric  ulcer,  carcinoma,  benign  growths,  obstructive 
duodenal  ulcer,  adhesions  from  pericholecystitis,  etc.).  The 
elongated  (ptosed)  stomach  shows  an  incidental  increase  of 
capacity.  The  functionally  hypotonic  or  atonic  stomach  is  ex- 
panded chiefly  at  its  lower  pole;  the  elongated  stomach  largely 
retains  its  tubular  form;  the  dilated  (ectatic)  stomach  is  enlarged 
throughout,  including  its  pyloric  portion,  which  is  not  only  ex- 
panded but  also  extends  well  to  the  right. 

Altered  Mobility. — It  should  here  be  repeated  that  lessened 
mobility  is  seen  normally  in  high-seated  and  hypertonic  stom- 
achs, not  only  because  they  are  situated  unfavorably  for  man- 
ipulation, but  also  because  they  are  short  and  more  or  less 
tensed  between  their  chief  suspension-points.  Apparent  dim- 
inution of  mobility  may  result  also  from  increased  tension  of  the 
abdominal  muscles.  However,  fixation  of  various  degrees  and 
at  various  points  may  ensue  from  perforating  ulcer,  carcinoma 
or  any  perigastric  inflammation  producing  adhesions.  Such 
fixation  may  be  evidenced  not  only  by  the  ineffectiveness  of 
efforts  at  shifting  by  palpation,  and  changing  the  patient's  posi- 


LESSENED    FLEXIBILITY  133 

tion,  but  also  by  the  failure  of  deep  respiration  to  alter  the  posi- 
tion of  the  affected  gastric  area.  In  rare  instances,  bands  of  ad- 
hesions may  produce  irregularity  of  the  gastric  contour  at  the 
adherent  point.  Fixation  of  the  pyloric  end  of  the  stomach  as 
a  result  of  inflammatory  processes  in  the  right  upper  abdominal 
quadrant  (pericholecystitis,  perforating  duodenal  ulcer)  we  have 
found  determinable  rather  seldom.  Palpatory  pressure  some- 
times merely  dislocates  the  gastric  contents  and  gives  the  im- 
pression that  the  gastric  wall  is  moved  also,  although  the  latter 
may  be  adherent.  On  the  other  hand,  an  apparently  fixed  area 
may  be  found  entirely  free  at  operation.  Excessive  mobility 
of  the  lower  pole  is  a  common  feature  of  hypotonic,  atonic  and 
ptosed  stomachs. 

Lessened  Flexibility. — Loss  of  flexibility,  as  shown  by  a  lack 
of  response  of  the  gastric  wall  to  narrow  palpation,  may  result 
from  any  infiltrative  process,  but  is  seen  characteristically  in 
extensive  carcinoma  and  in  the  ''leather-bottle  stomach."  Here 
the  infiltrated,  stiffened  wall  of  the  stomach  glides  away  from 
the  palpating  finger,  which  in  the  normal  stomach  produces  a 
correspondingly  narrow  indentation.  This  lack  of  pliability  is 
also  confirmed  by  the  local  or  general  restriction  of  expansion 
upon  adding  to  the  contents  of  the  stomach.  Somewhat  similar 
stiffening,  though  usually  of  a  lesser  degree,  may  be  seen  in 
gastrospasm,  but  an  intense  spasm  of  the  pars  pylorica  may 
temporarily  constrict  it  to  a  narrow,  rigid,  palpable  tube.  In 
judging  flexibility,  the  examiner  should  take  into  account  the 
accessibility  of  the  stomach  to  palpation.  A  high-seated  stom- 
ach can  be  little  affected  by  manipulation. 

Gas-bubble. — Variations  as  to  size  of  the  gas-bubble  have 
little  or  no  pathologic  significance.  In  aerophagy  the  bubble 
is  often  quite  large,  and  may  or  may  not  diminish  after  the  pa- 
tient belches. 

Normally  regular  and  symmetrical  in  outline,  its  contour 
may  be  broken  by  a  tumor  of  the  cardia,  by  splenic  or  hepatic 
tumors,  by  a  gas-distended  splenic  flexure  of  the  colon,  or  by 
herniation  through  the  diaphragm.     Carcinoma,   which  is  by 


134  THE   ABNORMAL   STOMACH 

far  the  most  common  intrinsic  tumor  involving  the  upper  cardia, 
usually  implicates  the  lesser-curvature  side,  and  opaquely  de- 
forms this  aspect  of  the  gas-bubble.  Gas  in  the  splenic  flexure 
is  more  likely  to  distort  the  outer  aspect  of  the  gas-bubble, 
and  the  haustrated,  translucent  colon  is  easily  distinguished. 

Secretion. — An  excessive  amount  of  secretion  is  sometimes 
discoverable  by  the  roentgen  examination.  The  upper  level  of 
the  accumulated  fluid  may  reach  nearly  or  quite  to  the  gas- 
bubble,  and  the  barium  as  swallowed  descends  through  it  slowly. 
After  filling  the  stomach  the  translucent  layer  between  the  gas- 
bubble  and  the  opaque  ingesta  is  extraordinary  wide.  Such 
hypersecretion,  or  retention  of  secretion,  is  more  likely  to  be  ob- 
served in  any  obstructive  condition  near  the  pylorus,  but  more 
particularly  in  gastric  ulcer,  or  duodenal  ulcer.  It  is  frequently 
associated  with  a  retention  from  the  six-hour  meal,  and  often 
with  some  degree  of  gastric  dilatation. 

Absence  or  diminution  of  secretion  may  be  also  more  or  less 
evident  in  the  achylia  of  carcinoma  or  after  gastro-enterostomy. 

Abnormal  Peristalsis. — Gastric  peristalsis  is  susceptible  of 
considerable  diversity  as  to  the  number  of  waves  to  be  seen  simul- 
taneously, their  energy  as  shown  by  their  depth,  their  frequency, 
regularity  of  succession  and  point  of  origin  and  termination. 
While  these  variations  may  occur  in  non-pathologic  conditions, 
as  mentioned  in  the  discussion  of  the  normal  stomach,  they  often 
possess  diagnostic  significance,  although,  as  Kaestle^  says,  the 
line  is  not  at  present  drawn  sharply  enough  to  make  it  always 
possible  to  say  positively  where  the  normal  ceases  and  the  ab- 
normal begins. 

Sluggish  peristalsis,  with  diminution  of  the  number  and  depth 
of  the  waves,  may  be  consequent  upon  low  acidity,  hypotonus, 
fright  or  disgust.  Kaestle^  remarks  that  in  atonic  ectasia  the 
peristaltic  waves  are  shallow  and  sluggish,  and  new-formation 
of  the  "antrum"  is  lacking.  This  faintness  of  peristalsis  in  the 
so-called  atonic  stomach  we  have  observed  repeatedly,  but  when 
a  wave  definitely  formed  we  have  been  able  nearly  always  to 
follow  its  progress  to  the  pylorus.     With  low  acids  peristalsis 


ABNORMAL    PERISTALSIS  135 

is  also  less  active.  While  Cannon"  admits  the  concomitant 
variation  of  acid  gastric  contents  and  peristalsis,  he  has  observed 
deep  and  strong  peristaltic  waves  in  the  stomach  when  the  con- 
tents were  strongly  alkaline.  In  our  experience  nervous  or 
apprehensive  persons  have  usually  shown  markedly  diminished 
peristaltic  activity,  and  its  initiation  was  often  delayed  until 
they  regained  their  composure.  The  increase  of  peristaltic  vigor 
by  hyperacidity  has  often  been  noted  and  the  tendency  of  hyper- 
tonus  to  be  associated  with  well-marked  peristalsis  has  already 
been  mentioned.  From  a  diagnostic  standpoint,  therefore, 
neither  moderately  diminished  nor  moderately  increased  peris- 
talsis has  any  import.  There  are  peristaltic  phenomena,  how- 
ever, which  are  definitely  abnormal  and  which  have  strong  diag- 
nostic significance.  These  include  absence  of  peristalsis,  either 
general  or  local,  hyperperistalsis,  irregular  peristalsis  and  anti- 
peristalsis. 

General  absence  of  peristalsis  may  be  due  to  extensive  car- 
cinoma, fibromatosis,  syphilis  or  general  gastrospasm.  The 
complete  inertia  of  the  stomach  is  striking,  although  in  non-ob- 
structive cases  there  is  usually  also  a  continuous  and  copious 
drainage  of  the  gastric  contents  through  a  gaping  pylorus.  In 
addition  to  the  absence  of  peristaltic  movement,  the  gastric 
contour  is  manifestly  deformed  by  widespread  filling-defects, 
and,  if  gastrospasm  be  eliminated,  the  presence  of  an  intrinsic 
organic  lesion  is  practically  certain. 

Absence  of  peristalsis  from  a  local  area  may  be  caused  by  a 
new-growth,  inflammatory  infiltration,  adhesions,  or  localized 
spasm  involving  that  segment  of  the  stomach.  While  the  af- 
fected zone  remains  immobile,  peristalsis  may  be  noted  in  the 
uninvolved  musculature  above  or  below,  and  this  feature  is 
often  of  service  in  detecting  early  or  small  organic  lesions. 

Hyperperistalsis,  with  an  increase  of  the  number  and  depth 
of  the  waves  on  both  curvatures,  is  seen  typically  in  obstructing 
lesions  of  the  duodenum  (Fig.  88).  WTiereas,  with  the  technic 
previously  described,  the  stomach  of  the  standing  patient  nor- 
mally shows  but  one  or  two  peristaltic  constrictions,  there  are 


136 


THE   ABNORMAL   STOMACH 


now  seen  three  or  more  waves,  rather  equally  indenting  both 
curvatures  and  regularly  succeeding  each  other.  The  appear- 
ance of  hyperperistalsis  is  often  delayed  for  several  minutes 
after  filling  the  stomach,  in  which  case  it  may  succeed  ordinary 
and  average  peristalsis.  Periods  of  hyperperistalsis  may  alter- 
nate with  less  active  periods.  Hyperperistalsis  may  occur  also 
with  non-obstructing  duodenal  ulcer  and  as  a  reflex  from  other 
extrinsic  irritations   (disease  of  the  gall-bladder  or  appendix, 


Fig.   88.— Hyperperistalsis. 

etc.)  but,  while  the  number  of  waves  is  increased,  their  depth 
is  less  exaggerated  than  in  duodenal  obstruction. 

The  hyperperistalsis  accompanying  organic  obstruction  at, 
or  proximal  to,  the  pylorus,  as  we  have  observed  it,  contrasts 
markedly  with  the  hyperperistalsis  of  duodenal  obstruction.  The 
hyperperistalsis  of  pyloric  and  prepyloric  obstruction  is  erratic 
in  character.  It  affects  the  greater  curvature  chiefly,  or  at  least 
more  than  the  lesser  curvature.  The  waves  are  often  eccentric 
and  disorderly ;  deep  and  shallow  waves  alternate  with  each  other 
and  often  with  irregular  spacing  between   (Fig.  89).     In  this 


ABNORMAL    PERISTALSIS  137 

connection  the  remarks  of  Kaestle''  are  worthy  of  quotation. 
He  says:  ''In  pyloric  stenosis  there  is  found  a  deepened,  vigorous 
peristalsis,  beginning  abnormally  high  in  the  stomach.  The 
finding  of  stenotic  peristalsis  in  an  ectatic  stomach  justifies  the 
diagnosis:  'Obstructive  ectasia,  not  atonic'  With  continued 
loss  of  muscular  power  in  pyloric  stenosis  and  obstructive  ectasia, 
there  remains,  at  least  early  after  ingestion,  visibly  deepened 
peristalsis.  Later  on,  one  sees  deep  contractions  of  the  gastric 
wall  only  in  the  first  moments  after  taking   the   meal,  often 


Fig.  89. — Hyperperistalsis  of  the  irregular  type. 

only  while  the  ingesta  are  flowing  in.  Finally,  only  by  energetic 
massage  does  one  obtain  a  contraction,  deep,  immovable,  and 
remaining  in  one  place,  until  this  also  no  longer  occurs  and  the 
mass  of  contents  lies  motionless  on  the  floor  of  the  stomach." 
Barclay^  states:  "A  normal  stomach  that  occasionally  shows 
very  powerful  waves  (or  successions  of  waves)  of  peristalsis 
with  periods  of  inactivity  between,  is  suggestive  that  peristaltic 
action  is  becoming  worn  out,  and  if  this  sign  is  observed  on  one 


138  THE   ABNORMAL  STOMACH 

or  two  occasions  it  is  practically  certain  that   obstruction   is 
present." 

Antiperistalsis,  the  first  radiologic  observations  of  which 
were  published  by  Jonas,  ^  consists  in  the  passage  of  contraction 
waves  in  a  reverse  direction,  i.e.,  from  the  pylorus  toward  the 
cardia  (Fig.  90).  Haudek^"^  states  that  the  waves  usually  arise 
in  the  antrum  pylori,  may  be  followed  along  the  greater  curva- 
ture to  the  point  separating  the  lower  from  the  middle  third, 
vary  in  their  depth,  and  may  alternate  with  normal  peristaltic 


Fig.    90. — Antiperistalsis.       All   the   waves   here   seen   are   moving   from   the   pylorus 

toward  the  cardia. 

waves.  He  considers  it  needless  to  say  that  the  occurrence  of 
vomiting  has  nothing  to  do  with  antiperistalsis  of  the  stomach. 
He  regards  antiperistalsis  as  a  sign  of  some  organic  alteration  in 
the  walls  of  the  stomach  or  duodenum,  and  has  noted  it  most 
frequently  in  pyloric  stenosis,  usually  on  a  basis  of  carcinoma  or 
ulcer,  although  it  is  not  an  invariable  concomitant  of  stenosis. 
He  mentions,  without  specific  reference,  the  finding  by  Hol^- 
knecht  and  Robinsohn  of  antiperistalsis  in  the  gastric  crises  of 


DISORDERED    MOTILITY  139 

tabes,  and  the  observation  by  Salomon  of  this  phenomenon  in 
neurasthenic  persons. 

We  have  observed  antiperistalsis  in  a  considerable  number 
of  cases.  Without  exception,  obstruction  was  present  or  motil- 
ity interfered  with  by  a  lesion  of  the  wall  of  the  stomach,  as  in- 
dicated by  a  six-hour  retention,  and  no  case  at  operation  failed 
to  show  an  organic  lesion.  In  most  instances  the  lesion  involved 
the  pyloric  ring  or  the  prepyloric  segment  of  the  stomach,  and 
was  usually  ulcer  or  carcinoma. 

The  exact  point  of  origin  of  the  antiperistaltic  waves  which 
we  have  seen  was  not  closely  investigated,  but  for  the  most  part 
they  were  first  noticed  in  the  vestibular  region,  and  were  seen 
only  on  the  greater  curvature.  Their  rate  of  regression  seemed 
to  be  about  the  same  as  the  forward  progress  of  peristalsis,  and 
they  disappeared  in  the  pars  media.  Wider  than  normal  waves, 
they  are  nearly  always  relatively  shallow,  sometimes  so  shallow 
that  careful  inspection  is  required  to  detect  them,  although  in 
the  illustration  here  shown  (Fig.  90)  the  waves  are  well  marked. 
Generally  they  appear  to  follow  each  other  in  fairly  regular 
sequence,  but  run  only  for  short  periods.  Haudek  expresses  the 
opinion  that  if  there  is  a  tendency  to  antiperistalsis  the  amplitude 
of  the  waves,  and  hence  their  visibility,  can  be  increased  by  any 
stimulus  which  will  increase  the  depth  of  ordinary  peristalsis. 

Disordered  Motility. — Abnormal  motihty  may  be  manifested 
either  as  an  acceleration  or  retardation  of  the  gastric  clearance. 

It  is  evident  that  the  double-meal  method  does  not  concern 
itself  with  hypermotiUty  in  terms  of  exact  time  of  evacuation, 
although  this  can  be  established  with  either  the  first  or  the 
second  meal  if  desired.  As  a  rule,  the  degree  of  hypermotiUty 
can  be  reckoned  by  the  advance  of  the  head  of  the  first 
meal  beyond  the  cecum,  plus  the  freedom  and  continuity  of  exit 
of  the  second  meal  through  the  pylorus.  It  is  true  that  the 
position  of  the  six-hour  meal  is  the  net  result  of  the  motility  both 
of  the  stomach  and  intestine,  but  in  the  absence  of  intestinal 
obstruction  as  shown  by  other  roentgen  signs,  or  severe  obstipa- 


140  THE   ABNORMAL   STOMACH 

tion  or  diarrhea  as  indicated  by  the  anamnesis,  the  intestinal 
factor  can  be  disregarded. 

In  the  presence  of  a  decided  hypermotihty  we  have  to  con- 
sider as  possible  causes  duodenal  ulcer,  gastric  carcinoma,  an- 
acidity  and  diarrhea.  The  report  of  the  gastric  analysis  or  the 
clinical  history  will  decide  as  to  anacidity  or  diarrhea,  respect- 
ively. The  most  typical  hypermotihty  is  seen  in  cancer  with  its 
gaping  pylorus,  which  may  be  infiltrated  and  stiffened  or  merely 
relaxed  by  the  anacidity.  The  flow  through  the  pyloric  open- 
ing is  continuous  and  frequently  voluminous,  and  the  six-hour 
meal  may  have  advanced  into  the  transverse  colon  or  beyond. 
The  hypermotihty  of  gastric  cancer  is  not  incompatible  with 
actual  narrowing  of  the  pylorus,  which  remains  steadily  open  and 
thus  more  than  compensates  for  the  narrowing.  Over  90  per 
cent,  of  gastric  cancers  will  reveal  other  roentgen  evidence  (filling- 
defects),  so  that  hypermotihty  is  by  no  means  a  principal  sign. 
The  hypermotihty  of  duodenal  ulcer  is  commonly  attributed  to 
interference  with  the  pylorus-closing  reflex  as  well  as  to  hyper- 
tonus  and  hyperperistalsis.  Here,  again,  these  factors  may 
balance  or  even  overcompensate  a  slight  organic  or  spasmodic 
stenosis  at  the  site  of  the  ulcer.  In  any  event,  most  of  the  cases 
of  duodenal  ulcer  will  show  hyperperistalsis  or  deformity  of  the 
bulb. 

An  initial  rapid  rate  of  clearance  of  the  second  barium  meal 
through  the  pylorus  is  not  alone  a  dependable  sign  of  hypermotil- 
ity;  advancement  of  the  six-hour  meal  in  the  colon  should  be 
present  also.  We  have  seen  numerous  cases  of  cholecystitis 
(with  and  without  periduodenal  adhesions)  chronic  appendicitis, 
hypochlorhydria  from  all  causes,  and  general  reflex  gastrospasm, 
in  which  the  clearance  was  large  and  uninterrupted  during  five 
or  ten  minutes'  examination,  yet  this  clearance  was  probably  not 
characteristic  of  the  whole  period  of  digestion,  since  the  six-hour 
meal  was  not  advanced  beyond  its  average  position.  By  the 
process  of  elimination,  few  cases  of  actual  hypermotihty  remain 
unexplained,  and  on  the  whole,  it  is  of  less  practical  importance 
than  its  converse. 


DISOKDERED    MOTILITY  141 

In  many  cases,  although  the  stomach  is  empty  at  six  hours, 
retarded  evacuation  is  evinced  by  the  motor  meal  lying  proxi- 
mal to  the  cecum,  together,  sometimes,  with  scanty  initial  py- 
loric clearance  of  the  second  meal.  For  such  retardation,  with  an 
emptying  time  greater  than  three  hours  but  less  than  six  hours, 
there  is  a  host  of  possible  causes,  including  depressive  psychic 
states,  weak  peristalsis,  hypotonus  or  so-called  atony,  high  hub- 
hohe,  ptosis,  all  of  which  occur  commonly  in  asthenic  persons, 
hyperacidity,  reflex  spasm  of  the  pylorus  and  slighter  grades  of 


Fig    91. — Six-hour  residue.     Retention  of  about  half  the  motor  meal. 

stenosis,  whether  uncompensated  or  only  partially  compensated. 
In  our  own  experience  organic  stenoses  causing  delayed  gastric 
evacuation,  but  within  six  hours,  have  not  been  frequent. 
Shortening  the  time  limit  to  say  five  hours  in  order  to  detect 
such  cases  would  probably  result  in  greater  error  by  including 
physiologic  and  functional  delays. 

The  six-hour  limit  allows  for  delay  resulting  mainly  from 
weakened  active  factors  of  motility — tonus  and  peristalsis.  De- 
lay beyond  six  hours  as  shown  by  a  definite  residue  (Fig.  91) 


142  THE   ABNORMAL   STOMACH 

signifies,  as  a  rule,  some  disturbance  of  the  passive  factor, 
namely,  organic  or  spastic  obstruction  at  or  near  the  pylorus. 
It  should  be  reiterated  that  this  delay  must  be  exhibited  in  a 
substantial  and  visible  residue,  not  mere  traces  held  in  the  gastric 
folds  nor  a  collection  in  the  lower  pole  so  small  that  it  can  be 
seen  only  with  difficulty.  With  a  retention  of  one-fourth  or 
more  of  the  meal,  there  is  probably  either  obstruction  of  an  or- 
ganic character  or  a  serious  lesion  interfering  reflexly  with  empty- 
ing. Among  the  causes  of  organic-  obstruction  we  have  noted 
duodenal  and  pyloric  ulcer  with  cicatricial  contraction,  hyper- 
trophic pyloric  stenosis,  pedunculated  benign  tumors  (polyposis) 
pyloric  cancer,  syphilis  of  the  stomach,  carcinoma  of  the  upper 
jejunum,  and  adhesion-bands  from  inflammatory  processes  in 
the  right  upper  abdominal  quadrant,  usually  pericholecystitis. 
Other  causes  of  obstruction  mentioned  in  the  literature  are 
foreign  bodies  (hair-balls,  fruit-stones,  etc.),  kinking  of  the 
prolapsed  stomach  at  its  duodenal  anchorage,  adhesions  from 
chronic  appendicitis,  and  tumors  outside  the  duodenum  press- 
ing on  it,  although  we  have  not  encountered  a  six-hour  reten- 
tion attributable  to  any  of  these,  except  possibly  the  last. 

Small  residues  down  to  an  eighth  or  less  of  the  motor  meal 
may,  of  course,  result  from  organic  narrowing.  A  more  common 
cause  is  spasm  of  the  pylorus  occurring  reflexly  from  a  lesion  of 
the  stomach  itself,  such  as  ulcer,  or  from  an  extrinsic  pathologic 
focus,  most  often  the  gall-bladder  or  appendix,  and  also,  but 
rarely,  from  more  remote  abdominal  lesions.  Holzknecht^^  has 
noted  the  possibility  of  a  six-hour  bismuth  residue  from  py- 
loric spasm  due  to  morphinism  or  a  single  administration  of 
morphin  at  the  time  of  examination. 

In  explaining  the  mechanism  bj^  which  gastric  retentions  are 
produced  in  the  absence  of  an  organic  stenosis,  roentgenologists 
have  frequently  assigned  ''pylorospasm"  as  a  cause.  By  the 
clinician,  the  term  is  limited  to  a  spasmodic  contraction  of  the 
pylorus  accompanied  by  pain,  vomiting,  etc.,  occurring  com- 
monly as  a  symptom  of  extragastric  conditions.  Roentgenolog- 
ically,  the  word  has  been  used  rather  broadly,  perhaps  somewhat 


DISORDERED    MOTILITY  143 

loosely,  to  cover  an  irritable,  or  hypertonic,  or  spastic  pylorus, 
which  relaxes  less  freely  or  less  frequently  than  the  normal 
pylorus,  regardless  of  symptoms. 

A  pylorus  which  is  not  organically  stenosed  is  not  infre- 
quently seen  to  remain  closed  continuously  or  for  abnormally 
long  periods  during  the  roentgen-ray  examination  of  anatomically 
normal  stomachs  showing  a  six-hour  retention,  and  w^hether  the 
term  ''pylorospasm"  be  strictly  applicable  or  not,  the  condition 
cannot  be  ignored  as  a  probable  cause  of  gastric  retention. 

To  differentiate  retention  due  to  pylorospasm  from  that  pro- 
duced by  organic  stenosis,  Sahli^^  has  made  use  of  sinking  and 
swimming  capsules.  The  distance  between  the  floating  capsule 
and  the  heavier  capsule  lying  at  the  bottom  of  the  stomach  gives 
an  idea  of  the  amount  of  fluid  in  the  stomach.  The  evacuation- 
time  of  water  can  be  shown  thus;  this  is  usually  normal  in  pjdoro- 
spasm  but  prolonged  in  stenosis.  According  to  Holzknecht 
and  Sgalitzer^^  the  administration  of  papaverin  hydrochloride 
shortens  the  emptying  time  in  pylorospasm  to  normal,  increases 
it  in  stenosis  and  has  no  effect  on  a  combination  of  the  two.  It 
may  be  given  in  a  dose  of  ^4  to  1  grain,  an  hour  before  the  in- 
gestion of  the  meal  for  a  second  examination. 

As  remarked  previously,  Hauclek  has  mentioned  the  high 
hubhohe,  that  is,  a  long,  steeply  ascending  pyloric  arm,  as  a  cause 
of  hypomotihty.  Of  very  similar  character  is  the  ''w^ater-trap 
stomach"  of  Satterlee  and  Le  Wald/"*  in  many  cases  of  which, 
with  the  technic  used,  six-hour  residues  were  noted.  In  both  of 
these  conditions  there  is  usually  a  degree  of  gastric  atony.  Can- 
non^^  holds  that  in  the  normal  stomach,  drainage  by  gravity  is  an 
unfortunate  conception,  that  the  food  is  in  exact  equihbrium 
and  that  muscular  action  is  necessary  to  its  progression.  Hau- 
dek  claims,  on  the  other  hand,  that  the  existence  of  an  impeding 
action  of  a  high  level  of  the  outlet  has  been  shown  experi- 
mentally, the  evacuation-time  being  shortened  when  the  patient 
lies  in  the  right  lateral  position  and  prolonged  when  the  patient 
lies  in  the  left  lateral  position. 

Neilson  andLipsitz^*'  have  found  from  experiments  on  healthy 


144  THE    ABNORMAL   STOMACH 

young  men  that  lying  on  the  right  side  produces  a  more  rapid 
evacuation  of  water  than  does  any  other  position,  and  that 
lying  on  the  back  causes  a  quicker  emptying  than  the  upright 
posture.  In  the  light  of  these  statements  it  would  appear  that 
while  gravity  probably  plays  a  minor  role  in  gastric  evacuation, 
as  compared  with  other  factors,  it  cannot  be  altogether  disre- 
garded. Whether  a  high  situation  of  the  pyloric  outlet,  without 
an  associated  gastric  atony,  may  or  may  not  cause  delay  of 
evacuation,  we  have  not  seen  such  delay  beyond  six  hours  with 
the  barium  meal.  Nor  have  we  noted  a  six-hour  residue  attribu- 
table simply  to  hyperacidity,  atony,  or  intestinal  stasis  with  or 
without  ''kinking  of  the  duodenum.  "  .  While  the  motility  of  the 
stomach  in  a  given  case  is  susceptible  to  some  variation  from 
time  to  time,  we  have  seldom  seen  a  six-hour  retention  which  did 
not  recur  at  a  subsequent  examination  if  a  lesion  was  present. 
However,  in  the  case  of  a  residue  without  any  other  diagnostic 
indications,  the  test  with  the  motor  meal  should  be  repeated  be- 
fore conclusions  are  drawn. 

The  interpretation  of  the  results  from  the  double-meal 
method  may  be  either  simple  or  complex  as  desired.  The  ob- 
server may  be  content  with  determining  the  presence  or  absence 
of  a  residue  at  the  end  of  six  hours.  With  the  presence  of  such 
a  residue  he  can  be  fairly  certain  of  organic  pathology  somewhere 
in  the  gastro-intestinal  tract,  and  probably  in  the  stomach  or 
duodenum.  Again,  he  may  take  cognizance  also  of  hypermo- 
tility  or  lesser  degrees  of  hypomotility.  Still  again,  he  may 
consider  the  results  in  the  light  of  all  the  discoverable  factors 
pertaining  to  motility,  including  the  gastric  form,  position, 
tonus,  peristalsis,  and  acidity.  Finally,  he  may  combine  and 
correlate  his  findings  with  other  roentgenologic  signs,  the  phys- 
ical examination  and  the  clinical  history.  By  the  construction 
of  "symptom-complexes"  in  this  manner  Holzknecht^^  was 
enabled  to  make  diagnoses  which  he  could  not  make  otherwise. 
Although  some  of  his  complexes  can  hardly  be  accepted  implic- 
itly, his  general  plan  of  weighing  the  roentgen  signs  in  com- 
bination with  each  other  and  in  conjunction  with  clinical  data 


DISORDERED    MOTILITY  145 

is  well  worth  while  and  we  have  followed  it  to  advantage.  While 
this  has  been  criticized  as  an  "indirect"  method  in  comparison 
with  the  "direct"  method,  namely,  that  of  proving  the  presence 
of  a  lesion  by  showing  local  deformity  of  contour,  we  can  only 
say  that  we  have  often  failed  to  discover  such  deformity  although 
the  symptom  and  sign-complex  established  the  diagnosis.  Cer- 
tainly deformity  of  contour  is  of  the  highest  roentgenologic 
value  and  should  be  zealously  sought,  but,  like  all  other  signs, 
it  fades  gradually  into  the  realm  of  uncertainty.  A  six-hour 
residue  is  a  strong  stimulus  to  careful  search  for  other  signs,  and 
if  the  latter  are  found,  the  presence  of  a  retention  is  added  assur- 
ance of  the  presence  of  a  lesion  and  that  it  is  interfering  with 
motility,  which  latter  information  is  highly  important. 

Gastric  retention  can  be  combined  into  various  indicative 
complexes.  A  six-hour  residue  with  a  stomach  of  normal  con- 
tour, showing  hyperperistalsis,  means,  more  than  ninety  times 
out  of  a  hundred,  obstructive  duodenal  ulcer.  Residue  plus 
an  apparently  normal  gastric  outline,  plus  an  irregular,  vigorous 
peristalsis,  chiefly  on  the  greater  curvature,  usually  signifies  a 
lesion  involving  the  pyloric  end  of  the  stomach.  A  residue 
with  an  achyUa,  but  without  gross  alteration  of  the  gastric  con- 
tour, should  suggest  the  probability  either  of  a  small  obstructing 
pyloric  carcinoma,  or  obstruction  of  the  duodenum  by  peri- 
cholecystic  adhesions;  careful  attention  to  the  pyloric  and  duod- 
enal contours  will  usually  make  the  distinction.  Residue  with 
hyperacidity  and  no  irregularity  of  the  gastric  or  duodenal  out- 
line would  indicate  a  stomach  reflexly  affected  by  some  other 
abdominal  condition,  notably  cholecystitis  or  appendicitis.  The 
possibilities  of  the  roentgenologic  estimation  of  motility  are  by 
no  means  exhausted.  The  method  described  in  detail  deals 
with  the  evacuation  of  a  carbohydrate  meal  only.  We  can  freely 
endorse  its  convenience  and  trustworthiness  in  the  diagnosis  of 
the  graver  and  usually  surgical  conditions.  By  a  mixed  meal 
and  extension  of  the  time  limit,  by  examination  at  short  inter- 
vals, or  by  testing  the  motility  of  each  individual  for  carbohy- 
drates, proteins  and  fats  separately,  the  diagnosis  of  slighter 


146 


THE   ABNOKMAL   STOMACH 


disturbances  of  motility,  amenable  to  medical  treatment,  might 
be  assisted.  However,  with  all  the  work  of  the  experimental 
physiologists  before  us,  no  meal  can  be  devised  the  normal 
emptying-time  of  which  can  be  foretold  with  certainty,  and  any 
test  must  be  proved  by  trial  with  abundant  material. 

ZONES  OF  MOTILITY  BASED  ON  THE  SIX-HOUR  MOTOR  MEAL 

Hour 


Zone  of  Hypermotility 


Zone  of  Normal  Motility 


Early  emptying,  pathologic.  (Non-obstruct- 
ing gastric  carcinoma.  Duodenal  ulcer. 
Diarrheic  conditions.     Achylia  gastrica.) 

Early  emptying,  physiologic.  (Hypertonic, 
steer-horn  stomach.) 

Early  emptying,  pathologic,  but  slight,  or 
partially  compensated.  (Duodenal  irrita- 
tion. Duodenal  ulcer  with  obstruction  suf- 
ficient to  prolong  the  evacuation-time  to 
two  hours  in  spite  of  associated  hyperperis- 
talsis,  hypertonus  and  free  pyloric  patency.) 

Normal  emptying.  (A  mornal  stomach  func- 
tionating in  a  normal  manner.) 

Disordered  motility  with  abnormal  but  balanced 
factors.  (Stenosing  carcinoma  with  achylia; 
average  emptying-time.) 

Delayed  emptying,  physiologic.  (Hypotonic 
fish-hook  stomach.) 

Delayed  emptying,  pathologic,  but  slight  or 
partially  compensated.  (Slight  stenosis. 
Stenosis  with  hyperperistalsis.) 


Zone  of  Hypomotility 


Delayed  emptying,  pathologic. 

Stenosis, 
(a)  Organic.  (Obstructing  pyloric  carcinoma. 
Pyloric  ulcer.  Obstructing  duodenal  ulcer. 
Periduodenal  adhesions,  etc.) 
(fe)  Spasmodic.  (Reflex  pylorospasm  from 
ulcer  on  well  above  the  pylorus,  cholecystitis, 
appendicitis,  and  remote  abdominal  lesions.) 


Etc. 


A  diagrammatic  representation  of  motility  may  assist  to  a 
clearer  understanding.  Taking  as  a  basis  a  meal  which  leaves 
the  normal  stomach  in  an  average  time  of  say  three  hours,  such 


ZONES    OF    MOTILITY  147 

as  the  bariumized  carbohydrate  meal,  we  may  divide  gastric 
evacuation  time  as  represented  on  a  scale  of  hours  into  three 
periods  or  zones,  viz.:  (1)  A  zone  of  normal  motility;  (2)  a 
zone  of  pathologic  hypermotility,  and  (3)  a  zone  of  pathologic 
hypomotility. 

1.  The  zone  of  normal  motility  must  extend  from  an  empty- 
ing-time somewhat  less  than  three  hours  to  an  emptying-time 
considerably  greater  than  three  hours,  since  we  can  fix  the  three- 
hour  point  only  as  an  average  on  either  side  of  which  a  variation 
may  be  due  to  purely  physiologic  causes.  Within  this  zone  we 
are  obliged  also,  as  a  conservative  measure,  to  include  slighter 
tendencies  to  hypermotility  or  hypomotility  from  causes  which, 
though  pathologic,  are  not  pronounced  or  are  compensated 
wholly  or  in  part.  General  knowledge  justifies  the  assump- 
tion that  such  variation  toward  hypermotility  is  not  wide, 
and  for  the  purpose  of  this  diagram,  we  may  choose  the  two- 
hour  point  as  the  normal  minimum.  The  variation  toward 
hypomotility  we  may  grant  to  be  much  wider;  Haudek  makes 
a  generous  allowance  to  the  end  of  the  sixth  hour  which  we 
will  accept.  The  contents  of  this  normal  zone  would  then 
include : 

(a)  Normal  motility.  (Example:  A  normal  stomach  func- 
tionating in  a  normal  manner.) 

(5)  Early  emptying,  physiologic.  (Example :  A  hypertonic, 
steer-horn  stomach.) 

(c)  Early  emptying,  pathologic,  but  partially  compensated. 
(Example:  Duodenal  ulcer  with  obstruction  sufficient  to  pro- 
long the  evacuation-time  to  two  hours  in  spite  of  an  associated 
hyperperistalsis,  hypertonus  and  free  pyloric  patency.) 

(d)  Disordered  motility  with  abnormal  but  balanced  factors. 
(Example:  Stenosing  carcinoma  with  achylia,  yet  with  a  net 
emptying- time  of  three  hours.) 

(e)  Delayed  emptying,  physiologic.  (Example:  A  some- 
what hypotonic  fish-hook  stomach.) 

(/)  Delayed  emptying,   pathologic,   but  partially  compen- 


148  THE   ABNOEMAL   STOMACH 

sated.     (Example:  Stenosis  with  hyperperistalsis,  emptying  be- 
ing retarded,  but  within  six  hours.) 

2.  The  zone  of  hypermotihty,  restricted  to  an  emptying- 
time  less  than  two  hours,  would  include  such  frankly  pathologic 
conditions  as  non-obstructing  gastric  carcinoma,  duodenal  ulcer 
and  diarrheic  conditions. 

3.  The  zone  of  hypomotility,  beyond  six  hours,  would  com- 
prise the  stenoses,  both  organic  and  spasmodic,  as  examples  of 
which  may  be  mentioned  obstructing  pyloric  carcinoma  or  ulcer, 
markedly  obstructing  duodenal  ulcer,  and  reflex  pylorospasm 
from  disease  of  the  gall-bladder,  or  gastric  ulcer  remote  from  the 
pylorus. 

As  a  matter  of  fact  we  know  that  these  zones  may  overlap 
each  other  and  that  time  alone  will  not  delimit  normal  from 
abnormal  motility.  The  diagram,  while  somewhat  practical  in 
a  way,  illustrates  the  time  factor  only,  and  as  said  before,  a 
final  opinion  must  rest  on  an  analysis  of  all  the  factors.  The 
roentgen  method  renders  this  analysis  both  possible  and  prac- 
ticable, and  herein  lies  its  superiority  to  the  test-meal  and  tube. 

Comparison  of  the  Results  Obtained  by  the  Roentgen -ray  and 
the  Stomach-tube. — Our  own  statistics  indicate  that  the  six-hour, 
bariumized,  carbohydrate  meal  is  a  more  sensitive  test  of  gastric 
motility  than  the  method  used  by  the  gastroenterologist.*  At 
the  Mayo  Clinic  during  the  year  1914  we  ran  a  series  of  950 
patients  who  had  been  examined  both  by  the  roentgen-ray  and 
the  test-meal  and  went  to  operation.  (This,  of  course,  does  not 
include  several  hundred  operated  cases  in  which  one  or  the 

*  At  6  p.m.  previous  to  the  day  of  examination  the  patient  takes  a  modified 
Riegel  meal;  that  is  to  say,  he  is  instructed  to  eat  an  ordinary  meal  which  must 
include  bread,  meat  and  potatoes.  An  hour  later  he  eats  20  raisins,  the  skins  of 
which  are  easy  to  identify  and  tend  to  remain  in  the  stomach  somewhat  longer 
than  the  usual  food  materials.  The  gastroenterologist's  examinations  are  begun 
the  next  day,  about  8  a.m.,  and  depending  on  the  number  of  patients  to  be  exam- 
ined, the  interval  after  the  motor  meal  varies  from  fourteen  to  sixteen  hours. 
The  estimate  of  motility  is  based  on  the  presence  or  absence  of  food-bits  or  raisin- 
skins  from  this  meal  as  shown  by  tubing  at  the  morning  examination.  The  gastro- 
enterologist's technic  includes  also  the  administration  of  a  modified  Ewald  test- 
breakfast  for  the  chemical  examination,  but  with  this  we  are  not  here  concerned. 


ROENTGEN-RAY   AND    STOMACH-TUBE  149 

other  motor  test  was  omitted.)  Two  hundred  and  twenty  of 
these,  or  23.1  per  cent.,  showed  at  the  roentgen  examination  a 
gastric  residue  from  the  six-hour  meal.  One  hundred  and  thirty- 
one,  or  13.7  per  cent.,  had  food  remnants.  In  other  words,  the 
roentgen-ray  show^ed  approximately  70  per  cent,  more  reten- 
tions than  the  clinical  test-meal.  The  lesions  found  w^ere:  Dis- 
ease of  the  appendix,  125  cases;  disease  of  the  gall-bladder,  311; 
gastric  ulcer,  109;  gastric  cancer,  137;  duodenal  ulcer,  268. 
The  accompanying  table  shows  the  incidence  of  retention  in 
each  of  these  conditions,  as  found  by  the  roentgen-ray  and  stom- 
ach-tube, respectively.  The  preponderance  of  six-hour  barium 
residues  over  food  remnants  from  the  clinical  test-meal  is  note- 
worthy, being  twice  as  great  in  gastric  ulcer  and  lesions  of  the 
gall-bladder;  almost  twice  as  great  in  duodenal  ulcer;  and  half 
again  as  large  in  gastric  cancer.  In  the  125  cases  with  lesions  of 
the  appendix,  a  retention  was  noted  by  the  roentgen-ray  in  only 
1  case,  and  found  in  only  2  cases  by  the  stomach-tube.  In  only 
12  of  311  cases  with  lesions  of  the  gall-bladder  was  retention 
noted  either  by  the  roentgen-ray  or  by  tubing.  The  vast  major- 
ity (209  or  90.4  per  cent.)  of  the  220  patients  showing  a  barium 
retention  were  found  at  operation  to  have  cancer  or  ulcer  of 
the  stomach  or  ulcer  of  the  duodenum. 

In  16  cases  representing  all  five  conditions,  the  stomach- 
tube  revealed  food  remnants,  while  no  six-hour  retention  of 
barium  was  found  by  the  roentgen-ray.  On  the  other  hand, 
105  patients  had  roentgen  residues  but  no  food  remnants. 

In  8  of  the  cases  tabulated  under  gastric  ulcer  there  was  also 
a  duodenal  ulcer.  All  of  these  patients  showed  a  residue  from 
the  barium  meal,  and  6  of  them  had  food  remnants. 

Besides  the  cases  tabulated  above,  residues  were  found  by 
the  roentgen-ray  in  one  patient  in  each  of  the  following  conditions : 
Cancer  of  the  pancreas,  tumor  of  the  ileum,  cancer  of  the  com- 
mon duct,  hydronephrosis,  tumor  about  head  of  pancreas,  tumor 
of  left  kidney,  subdiaphragmatic  abscess,  and  cancer  of  the  as- 
cending colon.  In  the  four  first  mentioned,  retention  was  noted 
also  by  the  gastroenterologist. 


150 


THE   ABXOEMAL   STOMACH 


How 


can  the  discrepancy  between  tlie  gastroenterologist's 
results  and  our  own  be  explained? 

1.  It  would  seem  probable  that 
the  time  elapsing  between  the 
ingestion  of  the  gastroenterologist's 
meal  and  its  withdrawal  is  too 
hberal,  and  that  the  stomach  was 
empty  in  many  instances  in  spite  of 
an  actual  and  pathologic  h3T)omo- 
tihty. 

2.  It  is  quite  possible  that 
the  tube  may  have  failed  occasion- 
ally to  bring  up  food  remnants 
which  were  present.  Harmer  and 
Dodd/'  by  watching  with  the 
roentgen-ray  the  introduction  of 
the  tube,  frequently  noted  that  the 
tip  impinged  against  the  gastric 
wall,  weU  above  its  most  dependent 
portion,  and  continued  efforts  to 
pass  the  tube  simply  caused  it  to 
ctirl  and  displace  the  tip  further 
upward.  In  other  instances  it  was 
foimd  that  by  passing  the  usual 
length  of  tube  in  cases  of  ptosis,  the 
tip  might  fail  to  reach  the  residuum. 
This,  they  beheve.  is  a  common 
error.  The  posture  of  the  patient 
and  the  position  the  stomach  occu- 
pies in  the  abdominal  ca^dty  affect 
the  success  of  tubage.  From  their 
observations  they  regard  it  as 
"obvious  that  failure  to  recover 
gastric  residuum  with  the  unaided 
stomach-tube  from  a  fasting 
stomach  or  after  the  ingestion  of  a 


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REFERENCES  151 

test-meal  cannot  be  accepted  as  conclusive  evidence  of  the  ab- 
sence of  gastric  stasis."  Rehfuss,  Bergeim  and  Hawk^^  have 
employed  a  tube  devised  on  the  principle  of  the  duodenal  tube, 
with  a  slotted  metal  tip,  which  by  its  weight  will  seek  the  most 
dependent  part  of  the  stomach.  In  instances  in  which  the  pas- 
sage of  the  ordinary  tube  failed  to  disclose  any  residue,  the  new 
tube  obtained  considerable  amounts.  They  found,  further,  in  a 
series  of  healthy  persons,  that  the  fluid  residuum  in  the  normal 
empty  stomach  far  exceeded  the  accepted  Umit  of  20  c.c,  and  in 
several  was  above  100  c.c. 

3.  The  tube  may  have  failed  to  reach  food  retained  in  the 
lower  loculus  of  an  hour-glass  stomach.  It  seems  probable  that 
this  occurred  in  at  least  one  instance  of  hour-glass  stomach  in 
which  the  roentgen-ray  showed  a  residue,  but  the  gastroenterolo- 
gist  reported  none. 

4.  Marked  differences  as  to  the  quantity  and  character  of 
the  food  taken  by  the  patient  may  have  affected  the  gastro- 
enterologist's  results. 

5.  In  exceptional  instances  of  organic  stenosis  at  the  py- 
lorus (cancer  or  ulcer)  the  tube  found  retained  raisin-skins 
when  the  roentgenologic  test  failed  to  show  a  barium  reten- 
tion. It  is  clear  that  a  stenosis  might  be  sufficiently  narrow  to 
block  the  passage  of  these  skins  and  yet  permit  a  fair  exit  of 
finely  divided  barium. 

REFERENCES 

1.  Adami,  J.  G.,  and  Nicholls,  A.  G.:  ''The  Principles  of  Pathol- 

ogy."    Phila.,  1909,  Lea  and  Febiger,  ii,  4(H. 

2.  ScHLESiNGER,  E. :  "  Weitcre  Auf schLtisse  tiber  der  Befund  und  die 

Genese   der    Gastroptose   durch  das   RontgenbiLd."     Deufsch. 
Arch.  f.  Min.  Med.,  1912,  Bd.  107,  H.  5  and  6,  552-572. 

3.  Groedel,  F.  M. :  "Atlas  und  Grundriss  der  Roentgendiagnostik." 

Mtinchen,  J.  F.  Lehman,  1909,  200. 

4.  Kaestle,  K.  :  Rieder-Rosenthal,  "Lehrbuch  der  Rontgenkunde." 

Leipsig,  J.  A.  Barth,  1913,  i,  509. 

5.  Kaestle,  K.:  Ibid.,  520. 

6.  Cannon,  W.  B.:  "The  Mechanical  Factors  of  Digestion."     New 

York,  Longmans,  Green  and  Co.,  1911,  56. 


152  THE   ABNORMAL   STOMACH 

7.  Kaestle,  K.:  Op.  cit.,  520. 

8.  Baeclay,  a.  E.:  "The  Stomach  and  Esophagus."     New  York, 

Macmillan  Co.,  1913,  34. 

9.  Jonas,  S.:  "Ueber  Antiperistaltik  des  Magens."     Deutsch.  Med. 

Wchnschr.,  1906,  xxxii,  916-919. 

10.  Haudek,  M.:  "The  Diagnostic  Value  of  Gastric  Antiperistalsis." 

Arch.  Roentgen  Ray,  1913,  xvii,  312-317.  Translated  and  con- 
densed from  the  Wien.  Med.  Wchnschr.,  1912,  No.  16. 

11.  HoLZKNECHT,   G.:  "The  Roentgen  Diagnosis  of  the  Stomach." 

Arch.  Roentgen  Ray,  1911,  xvi,  206. 

12.  Quoted    by   Haudek:  "Ueber    die    Racliologische    Priifung    der 

Magenmotilitat  und  Ihre  Resultate."  Fortschritte  a.  d.  Geb.  d. 
Roentgenstrahlen,  1914,  xxi,  472-479. 

13.  HoLZKNECHT,  G.  and  Sgalitzek,  M.:  "Papaverin  zur  roentgeno- 

logischen  Differentialdiagnose  zwischen  Pylorospasmus  und 
Pylorusstenose."  Milnch.  Med.  Wchnschr.,  1913,  Ix,  1989- 
1993. 

14.  Satterlee,  G.  R.  and  Le  Wald,  L.  T.:  "One  Hundred  Cases  of 

Water-trap  Stomach."     Jour.  A.  M.  A.,  1913,  Ixi,  1340-1350. 

15.  Cannon,  W.  B.:  "The  Mechanical  Factors  of  Digestion."     New 

York,  Longmans,  Green  &  Co.,  1913,  47. 

16.  Neilson,  C.  H.  and  Lipsitz,  S.  T.:  "The  Effect  of  Various  Pro- 

cedures on  the  Passage  of  Liquids  from  the  Stomach."  Jour. 
A.  M.  A.,  1915,  Ixiv,  1052-1055. 

17.  Harmer,  T.  W.,  and  Dodd,  W.  J.:  "Sources  of  Error  in  the  Use 

of  the  Stomach-tube  for  Diagnosis.  Preliminary  Report." 
Arch.  Int.  Med.,  1913,  xii,  488-502. 

18.  Rehfuss,  M.  E.,  Bergeim,  0.  and  Hawk,  P.  B.:  "  Gastro-intes- 

tinal  Studies :  The  Question  of  Residuum  Found  in  the  Empty 
Stomach."     Jour.  A.  M.  A.,  1914,  Ixiii,  11-13. 


CHAPTER  VIII 
GASTROSPASM 

The  roentgenologic  diagnosis  of  disease  in  the  digestive  tract 
requires  a  thorough  famiUarity  with  spasm  of  the  visceral  mus- 
culature, its  numerous  manifestations  and  their  relative  signifi- 
cance. Though  recognized  early  by  roentgen  workers  and  men- 
tioned occasionally  in  the  literature,  spastic  phenomena  deserve 
increasing  attention  and  study,  because  they  are  relatively  com- 
mon and  occasionally  very  perplexing. 

Organic  deformity  of  the  lumenal  contour  is  the  principal 
direct  roentgenologic  sign  of  disease  in  the  digestive  tube.  It 
is  the  mainstay  of  roentgen  diagnosis,  not  only  evidencing  a 
lesion  but  directly  revealing  its  seat,  its  extent  and  often  its 
character.  Conspicuous  examples  of  organic  deformity  are  seen 
in  the  filling-defect  resulting  from  gastric  cancer  and  the  niche  of 
chronic  penetrating  gastric  ulcer,  the  diagnostic  value  of  which 
must  be  conceded. 

■'  Many  roentgenologists  refuse  to  make  a  diagnosis  in  the  ab- 
sence of  these  signs,  and  claim  that  ''sign-complexes"  made  up 
of  indirect  manifestations  are  of  no  value.  This  view  is  far  too 
radical,  for  the  fact  remains  that  if  roentgen  diagnoses  were 
limited  to  cases  in  which  these  direct  indications  are  noted,  many 
lesions  of  the  alimentary  canal  would  pass  undiscovered.  At 
present  we  are  often  obliged  to  rely  for  diagnosis  upon  more  re- 
mote phenomena,  such  as  alterations  of  motility,  tonus  and 
peristalsis.  All  of  these  can  be  materially  affected  by  spasm, 
further,  we  are  also  more  or  less  dependent  upon  changes  of  con- 
tour, spastic  in  nature  but  set  up  by  an  intrinsic  lesion,  as,  for 
example,  the  incisura  and  spasmodic  hour-glass  of  gastric  ulcer. 
Still  further,  and  what  is  even  more  important,  we  encounter  and 
must  be  able  to  recognize  spastic  deformity  of  outline  produced 

153 


154  GASTROSPASM 

reflexly  by  extrinsic  conditions  remote  from  the  deformed  organ. 
Such  deformity  may  deceptively  simulate  the  distortion  pro- 
duced either  directly  or  indirectly  by  an  intrinsic  lesion.  Thus 
the  roentgenologist  is  called  upon  to  deal  with  two  types  of  spasm. 
Probably  identical  in  the  mechanism  of  their  production,  namely, 
an  irritant  acting  through  a  reflex  arc,  they  nevertheless  differ 
widely  in  significance.  In  the  one  instance  the  termini  of  the  arc 
lie  within  the  same  organ;  in  the  other,  within  different  organs. 
One  is  most  often  a  help  to  diagnosis;  the  other  most  often  a 
hindrance.  By  a  pardonable  ellipsis  we  may  speak  of  the  one 
form  of  spasm  as  intrinsic;  the  other  as  extrinsic. 

All  divisions  of  the  digestive  tube  are  subject  to  spasm,  and 
it  is  so  frequently  met  with  that  it  must  be  kept  continually  in 
mind  by  the  examiner.  Spasm  of  the  esophagus  has  already 
been  mentioned.  Spasm  of  the  small  intestine  and  colon  will  be 
referred  to  in  their  respective  chapters. 

The  favorite  playground  of  spasm,  whether  of  intrinsic  or 
extrinsic  origin,  is  the  stomach.  Spasm  of  the  stomach,  arising 
from  an  intrinsic  lesion,  is  most  generally  produced  by  ulcer,  less 
often  by  cancer. 

Three  forms  of  spasm  due  to  gastric  ulcer  may  be  distin- 
guished : 

1.  The  incisura  or  hour-glass, stomach. 

2.  Diffuse  spastic  distortion:. 

3.  Spasm  of  the  pyloric  sphincter. 

1.  The  incisura,  the  spastic  indentation  of  the  greater  curva- 
ture in  the  plane  of  an  ulcer,  has  been  described  previously. 
Usually  narrow,  but  of  variable  depth,  persistent  and  permanent 
as  to  situation,  it  suggests  at  once  the  nature  of  the  lesion  and 
points  toward  its  site.  The  cavity  of  the  ulcer  itself  may  be 
seen  often  as  a  niche  or  pocket,  but  sometimes  neither  can  be 
distinguished.  In  the  latter  event,  the  incisura  either  alone  or 
in  combination  with  other  indirect  signs  may  guide  to  the  diagno- 
sis which  otherwise  could  not  be  made  (Fig.  92). 

When  the  incisura  is  deep  the  stomach  is  bilocular  and  may 
either  be  described  as  an  hour-glass  stomach,  or  the  incisura  only 


GASTROSPASM 


155 


Fig.  92. — Spastic  incisura  at  a,  opposite  an  ulcer  on  the  posterior  wall  near  the  lesser 

curvature. 


Fig.  93. — Spastic  hour-glass  at  a  accompanying  perforating  gastric  ulcer,  6. 


156 


GASTROSPASM 


may  be  given  emphasis  by  the  examiner.  In  other  instances  the 
width  and  depth  of  the  constriction  are  so  extreme  that  the 
characteristics  of  a  typical  incisura  are  lost,  and  a  pronounced 
hour-glass  form  is  seen  (Fig.  93) . 

2.  Gastric  ulcer  often  gives  rise  to  a  diffuse  spasm  affecting  a 
considerable  extent  of  the  pyloric  segment,  whether  the  ulcer  be 
situated  in  this  region  or  higher  up  in  the  stomach.  The  stom- 
ach, well  outlined  in  its  upper  portion,  shades  off  into  a  poorly 


Fig.   94. — Diffuse  spasm,  pyloric  portion  of  stomach  at  a,  in  association  with  a  gastric 
iilcer,  the  crater  of  which  can  be  seen  at  6. 


filled,  vaguely  outlined,  antral  area,  resembling  the  filling-defect 
of  a  pyloric  cancer  (Fig.  94) .  By  manipulation  the  opaque  in- 
gesta  can  sometimes  be  forced  into  that  part  of  the  stomach  so  as 
to  give  it  a  normal  outline,  but  when  manipulation  ceases  the 
defect  reappears.  This  diffuse  spasm  may  be  the  sole  roeatgeno- 
logic  sign  of  the  ulcer. 

3.  An  ulcer  situated  in  the  pyloric  segment  is  rather  fre- 
quently accompanied  by  a  retention  from  the  six-hour  meal. 
Ulcers   situated  well   away   from  the    pylorus    are    also    often 


GASTROSPASM 


157 


associated  with  a  six-hour  retention.  This  retention  has  been 
variously  ascribed  to  reflex  pylorospasm  from  the  ulcer,  to 
impairment  of  peristalsis  by  the  ulcer  and  to  pyloric  spasticity 
excited  by  hyperacidity.  Be  this  as  it  may,  we  have  seen  cases 
in  which  a  retention  from  the  six-hour  meal  was  the  only  dis- 
coverable sign  of  the  ulcer. 

Cancer  of  the  stomach,  aside  from  the  organic  filling-defect 
produced  by  the  tumor-mass,  may  produce  also  more  or  less 


Fig.  95. — Spastic  incisura  at  a;  small  mucoid  cancer  posterior  wall. 


spastic  distortion  of  the  gastric  contour.  For  example,  a  cancer 
involving  only  a  portion  of  the  lesser  curvature  may  be  accom- 
panied by  a  spastic  indrawing  of  the  greater  curvature  opposite 
the  lesion.  When  present,  it  is  usually  of  considerable  width 
and  exaggerates  the  lumenal  narrowing  produced  by  the  tumor. 
The  examiner  is  quite  apt  to  regard  the  broad  incisura  as  a  part 
as  the  organic  filling-defect,  but  generally  the  incisura  is  sharply 
sketched,  while  the  filhng-defect  shades  off  gradually.  The  mat- 
ter becomes  of  importance  in  forming  an  opinion  as  to  the  prob- 
able extent  of  the  cancerous  invasion.     In  rare  instances  a  spas- 


158  GASTROSPASM 

tic  incisura  ma^^  be  the  only  definite  roentgen  manifestation  of  a 
small  cancer  (Fig.  95). 

All  of  the  above-described  spastic  phenomena  are  intrinsic, 
that  is  to  say,  they  originate  from  lesions  of  the  stomach  itself. 
Quite  as  frequent,  perhaps  even  more  frequent,  are  the  extrinsic 
spasms — those  which  accompany  abnormal  conditions  outside 
the  stomach,  often  remote  from  it. 


Fig.  96. — Apparent  filling  defect,  pyloric  segment,  at  a.     At  operation  disease  of 
the  gall-bladder  was  found  but  no  lesion  of  the  stomach. 

One  of  these  spasms  takes  the  aspect  of  an  incisura  which  is 
much  hke  that  of  gastric  ulcer  but  usually  is  either  intermittent, 
or  progresses  toward  the  pylorus  hke  a  gigantic  peristaltic  wave. 
Occasionally  a  marked  hour-glass  form  of  the  stomach  which 
uiSij  either  relax  suddenly  or  persist  throughout  the  entire  period 
of  examination,  has  an  extrinsic  cause,  though  it  is  diflScult  for 
the  examiner  to  abandon  his  suspicion  of  the  presence  of  a  lesion 


GASTROSPASM 


159 


in  the  stomach.  Intermittent  and  traveUng  incisurge  and 
transient  hour-glass  contraction  of  the  stomach  seem  to  occur 
more  often  in  conjunction  with  duodenal  ulcer  than  with  any 
other  morbid  condition.  Equally  misleading  is  a  spastic  filling- 
defect,  of  extrinsic  origin,  occurring  more  commonly  in  the  py- 
loric end  of  the  stomach,  and  resembling  a  pyloric  cancer  or  the 
diffuse  spasm  provoked  by  a  gastric  ulcer  (Fig.  96). 

In  many  instances  after  a  barium  meal  is  given  none  of  it 
is  seen  to  pass  the  pylorus  for  several  minutes.     The  total  and 


Fig.  97.- — Spasm  of  the  pyloric  segment  producing  a  spigot-like  appearance. 


free  acidity  are  not  unduly  high,  and  there  may  or  may  not  be 
a  residue  from  the  six-hour  meal.  At  operation  cholecystitis  or 
chronic  appendicitis  is  found,  but  no  lesion  of  the  stomach.  In 
such  cases  there  is  evidently  a  pylorospasm,  not  necessarily  in 
the  clinical  sense,  but  a  spasticity  of  the  pyloric  sphincter,  for 
which  the  only  explanation  that  can  be  offered  is  the  diseased 
gall-bladder  or  appendix.  Sometimes  the  entire  pyloric  third 
of  the  stomach  is  shrunken  to  a  stiff  narrow  tube  which  may  be 
palpable  to  the  examining  fingers.     The  tube  projects  like  a 


160  GASTRO SPASM 

spigot  from  the  well-expanded  fundus,  and  shows  a  striking 
hkeness  to  the  canal  through  a  pyloric  tumor.  This  species  of 
spasm  has  disease  of  the  gall-bladder  as  its  usual  associate 
(Fig.  97). 

The  foregoing  extrinsicaUy  caused  spastic  manifestations 
are  all  localized  or  regional,  but  spasm  from  an  outside  source 
may  affect  the  entire  gastric  musculature,  giving  rise  to  what 
Holzknecht  and  Luger^  have  called  ''total  gastrospasm."  This 
may  be  characterized  as  a  gastric  hypertonus  which  far  exceeds 
physiologic  limits  and  renders  the  stomach  contracted,  tense 
and  inert.  The  stomach  is  ^dsiblj^  diminished  in  size.  The  gas- 
bubble  is  small.  Little  secretion  is  present  as  a  rule.  Canali- 
zation is  dela^^ed,  the  first  swallows  of  the  meal  being  held  high 
in  the  fundus.  With  continued  filling  the  ingesta  finally  reach 
the  pylorus,  and  the  stomach  assumes  a  fish-hook  form  but  of 
diminutive  size.  It  lies  up  under  the  left  costal  arch  and  en- 
tirely to  the  left  of  the  spine.  On  further  addition  to  the  gastric 
content  the  fundus  expands  to  accommodate  it,  but  the  pyloric 
portion  remains  narrow.  Peristalsis  is  usually  absent  alto- 
gether, although  there  may  be  a  few  faint,  irregular  waves. 
The  gastric  contour  lacks  the  smooth  regularity  of  the  normal 
filled  stomach,  being  finely  notched  and  broken  here  and  there. 
^Mobility  and  flexibihty  are  not  only  actually  lessened  somewhat 
by  the  stiffened  spastic  gastric  wall,  but,  by  reason  of  the  high 
sheltered  position  of  the  stomach,  it  often  seems  to  be  practi- 
cally immobile  and  inflexible.  The  pyloric  sphincter,  on  the 
other  hand,  may  remain  steadil}^  open,  and  there  is  an  early, 
free  and  continuous  exit  of  the  bariumized  meal.  The  whole 
picture  is  much  like  that  of  an  extensive  gastric  cancer  and 
might  easily  deceive  the  unwary  (Fig.  98).  It  should  be  reiter- 
ated that  the  frequent  resemblance  of  reflected  gastrospasm, 
whether  local,  regional  or  total,  to  the  filling-defect  of  a  cancer, 
makes  it  a  source  of  danger,  not  only  to  the  novice  but  to  the 
expert  as  well.  It  follows  that  in  the  presence  of  what  seems 
to  be  a  filling-defect,  precautions  should  always  be  taken  to  ex- 
clude the  possibility  of  spasm. 


GASTROSPASM 


161 


Fig.   98. — Total    gastrospasm.     Note  marked  irregularity  of  stomach  and  gaping 
pylorus.     The  two  views,  taken  with  only  a  brief  interval  between,  show  that  the  gastric 
deformity,  though  persistent,  varies  in  aspect,  thus  distinguishing  it  from  deformity  due 
toan  organic  lesion. 
H 


162  GASTEOSPASM 

To  sum  up,  the  manifestations  of  gastrospasm  from  an  ex- 
trinsic reflex  include  the  following : 

1.  Displacement  of  the  stomach  upward  and  to  the  left. 

2.  Diminution  of  gastric  capacity. 

3.  Small  size  of  the  gas-bubble  and  small  amount  of  secretion. 

4.  Tardy  canalization. 

5.  Lessened  mobility  and  flexibility  of  the  stomach. 

6.  Disturbance  of  peristalsis: 
(a)  Diminution. 

(6)  Exaggeration. 

7.  Disturbance  of  the  pyloric  function: 
(a)   Gaping  of  the  pylorus. 

(6)  Spastic  contraction  of  the  pylorus. 

8.  Incisura-production  and  hour-glass  form  of  the  stomach. 

9.  Deformity  and  pseudo  filling-defects  of  the  gastric  con- 
tour, either  local  or  general. 

Etiology. — Admittedly  the  etiology  of  gastrospasm  from 
causes  outside  the  stomach  is  hardly  susceptible  of  flawless 
proof.  The  association  of  duodenal  ulcer,  disease  of  the  gall- 
bladder and  appendix,  hysteria  and  fright  with  gastrospasm  is 
so  frequent  that  the  assumption  of  an  etiologic  relationship 
seems  only  rational.  Other  probable  causes  which  have  been 
noted  include  pancreatic  disease,  tabes,  arteriosclerosis  affecting 
the  abdominal  viscera,  renal  and  ureteral  calculi,  uremia,  and 
poisoning  by  lead,  nicotin  and  morphin.  Through  the  agency 
of  the  sympathetic  to  which  it  responds  readily,  the  stomach 
obviously  might  be  affected  reflexly  by  these  and  many  other 
disorders. 

Differentiation. — Given  a  case  which  shows  an  irregularity 
of  the  gastric  contour,  the  examiner  must  determine,  as  far  as 
he  can,  whether  the  distortion  is  due: 

1.  To  an  organic  lesion  producing  deformity  directly  at  the 
seat  of  the  lesion,  or 

2.  To  spasm  set  up  by  a  lesion  of  the  stomach,  or 


DIFFERENTIATION  163 

3.  To  spasm  occasioned  by  or  associated  with  abnormal  con- 
ditions elsewhere  than  in  the  stomach. 

This  is  best  carried  out  by  a  process  of  exclusion,  for  while 
a  parallel  tabulation  of  the  traits  of  these  three  conditions  shows 
some  discouraging  similarities,  there  are,  nevertheless,  certain 
practical  tests  by  which  differentiation  can  be  effected  in  most 
instances. 

1.  Deformity  of  the  gastric  outline  produced  by  an  organic 
lesion  is  persistent,  constant  in  situation  and  unvarying  in  as- 
pect. If  due  to  a  new-growth  and  accessible  to  manipulation, 
a  palpable  mass  corresponding  to  the  defect  may  sometimes  be 
found.  Its  borders  are  sometimes  sharp,  but  more  often  gradu- 
ally shaded,  and  frequently  the  alternating  elevations  and  de- 
pressions are  seen  as  if  in  a  stereoscopic  view.  It  may  be  either 
painful  or  tender.  The  niche  and  accessory  pocket  of  gastric 
ulcer  are  pathognomonic  of  themselves.  Adhesions  about  the 
stomach  are  relatively  rare,  except  those  resulting  from  perforat- 
ing gastric  ulcer  and  disease  of  the  gall-bladder,  and  they  do  not 
often  deform  the  gastric  contour. 

If  the  gastric  lumen  near  the  pylorus  is  markedly  encroached 
upon  by  an  organic  process,  some  degree  of  obstruction  will  be 
evident.  The  irregularity  of  contour  is  still  seen  at  repeated 
examinations.  It  cannot  be  made  to  disappear  by  giving  an 
antispasmodic. 

2.  Spasm  resulting  directly  from  an  ulcer  or  cancer  in  the 
stomach  is  manifest  usually  in  the  segment  involved,  and  espe- 
cially in  the  area  opposite  the  lesion.  It  tends  to  be  constant 
in  situation.  As  a  rule,  it  is  persistent  and  continuous,  although 
it  has  been  claimed  that  shallow  erosions  may  cause  intermittent 
spasm.  The  intensity  of  contraction  may  vary  from  time  to 
time  and  thus  alter  its  appearance.  Its  border  is  generally 
clear  cut,  but  it  may  show  as  an  indefinite  zone  of  incomplete 
filling.  The  spastic  area  is  not  painful  or  tender,  though  there 
may  be  pain  or  tenderness  localized  to  the  causative  lesion 
The  lesion  provoking  the  spasm  may  be  seen  as  a  niche,  accessory 
pocket  or  a  neoplastic  filling  defect.     The  progress  of  the  meal 


164  GASTROSPASM 

may  or  may  not  be  retarded,  depending  upon  the  extent  of  the 
lesion  rather  than  upon  the  spasm,  unless  the  pyloric  ring  is 
imphcated.  The  spasm  tends  to  persist  at  subsequent  exami- 
nation; it  does  not  disappear  after  giving  antispasmodics. 

3.  Indirect  and  remotely  caused  gastrospasm  is  often  brief  in 
duration  or  intermittent  in  appearance.  It  may  be  of  the  mi- 
gratory type,  traveling  toward  the  pylorus  like  a  peristaltic  wave, 
or,  though  continually  present  in  one  situation,  show  a  changing 
aspect  from  time  to  time.  No  tumor-mass  corresponding  to  the 
defect  can  be  felt  ordinarily,  and  the  exceptional  spasm  which 
produces  a  palpable  stiffening  of  the  gastric  wall  merely  proves 
the  rule.  The  borders  of  the  spastic  area  usually  are  sharply 
delineated  but  if  the  spasm  is  shifting  during  the  time  of  the 
exposure,  the  gastric  contour  may  be  hazily  blurred  in  outline. 
The  patient  does  not  complain  of  pain  at  its  seat,  nor  is  it  tender 
to  pressure.  Aside  from  marked  pylorospasm,  spasms  of  the 
gastric  musculature  do  not  give  rise  to  any  characteristic  sub- 
jective symptoms.  Unless  spasm  involves  the  pyloric  sphincter, 
it  tends  to  accelerate  gastric  motility  rather  than  retard  it. 

Remotely  reflected  spasrn  is  likely  to  he  absent  at  a  second 
examination.  It  almost  invariably  disappears  after  the  administra- 
tion of  an  antispasmodic  to  physiologic  effect  (Figs.  99  and  lOO). 

Of  course,  it  will  be  readily  understood  that  these  differential 
features  are  not  absolute  and  inflexible,  and  the  examiner  may 
occasionally  be  foiled  in  a  satisfactory  analysis  of  his  findings. 
At  any  rate,  he  ought  not  to  omit  any  method  that  will  eliminate 
indirect  spasm  from  the  field  of  consideration. 

A  prime  quality  of  remotely  reflected  spasm  is  its  instability, 
so  that  a  second  examination  alone  may  suffice  to  exclude  it. 
A  practical  test,  upon  which  most  roentgenologists  rely  for  the 
exclusion  of  reflex  spasm,  is  the  administration  of  belladonna  or 
its  alkaloid.  Irregularity  of  contour  produced  by  a  new-growth, 
infiltration  or  adhesions  of  the  gastric  wall  is  of  course,  not 
altered  by  this  drug.  Likewise,  the  spasm  arising  directly  from 
a  lesion,  such  as  the  incisura  of  gastric  ulcer^  withstands  its 
influence.     Spasm  reflected  from  a  distant  source  vanishes. 


DIFFERENTIATION 


165 


Fig.  99. — Spasmodic  hour-glass  stomach  from  an  extrinsic  cause. 


Fig.  100. — Same  case  as  Fig.  99.     Hour-glass  effaced  after  giving  belladonna. 


166  GASTROSPASM 

We  have  obtained  the  best  results  by  giving  belladonna  in  the 
form  of  the  tincture  in  doses  of  15  to  20  drops,  three  times  daily 
for  two  or  three  days,  and  then  reexamining.  The  essence  of  the 
test,  however,  does  not  depend  on  any  arbitrary  dose,  but  on  ob- 
taining the  physiologic  effects  of  the  drug,  as  shown  by  dryness 
of  the  throat,  dilatation  of  the  pupils,  etc.  If  the  effects  are  not 
obtained  the  second  examination  will  be  inconclusive.  Hence 
the  patient  should  be  seen  once  or  twice  daily  and  the  dose  in- 
creased, if  necessary.  On  the  other  hand,  the  patient  may  have 
an  idiosyncrasy  for  belladonna  and  this  should  be  kept  in  mind. 
To  save  time,  atropin  sulphate  in  a  dose  of  Koo  to  Ho  grain  may 
be  given  hypodermatically  and  the  second  examination  made  a 
half-hour  or  an  hour  later.  We  do  not  use  atropin  hypoder- 
matically because  it  is  difficult  to  determine  the  dose  necessary 
to  produce  a  physiologic  effect  in  a  given  case. 

Spasm  of  any  sort,  whether  intrinsic  or  extrinsic,  disappears 
under  general  anesthesia.  The  spasmodic  hour-glass  stomach, 
due  to  an  intrinsic  cause  and  persisting  after  giving  belladonna 
to  physiologic  effect,  is  not  present  at  operation  because  it  is 
relaxed  by  deep  narcosis.  Consequently,  the  surgeon  finding  no 
hour-glass  on  opening  the  abdomen  may  complain  that  the 
roentgen  diagnosis  is  incorrect,  and  conclude  that  it  is  needless 
to  look  for  any  trouble  in  the  stomach.  However,  a  careful 
search  will  usually  reveal  a  lesion,  either  in  the  stomach,  or, 
exceptionally,  in  the  duodenum. 

In  this  connection  we  might  say  that  while  belladonna  usually 
relaxes  gastrospasm  arising  from  extrinsic  causes,  the  incisura 
or  hour-glass  contraction  of  the  stomach  associated  with  duod- 
enal ulcer  appears  to  be  an  exception,  for  we  have  seen  several 
instances  in  which  this  variety  of  spasm  withstood  the  bella- 
donna test. 

The  employment  of  papaverin  and  of  Sahli's  capsules  to 
differentiate  spastic  retentions  from  those  due  to  organic  ob- 
struction has  been  described  in  the  discussion  of  disordered 
motiUty. 


DIFFERENTIATION 


167 


Fig.   101. — Hour-glass  contraction  at  a,  with  distal  narrowing. 


Fig.  102. — Same  case  as  Fig.  101.     Stomach  of  normal  contour  after  giving  an  anti- 
spasmodic. 


168  GASTROSPASM 

Case  112,360.  Female,  aged  39  j^ears.  For  twenty-two  years^  at 
intervals  of  one  to  foiu'  years,  the  patient  has  had  attacks  of  severe 
abdominal  pain  lasting  for  as  long  as  one  week.  The  attacks  usually 
begin  with  weakness,  loss  of  appetite  and  bloating,  these  sjTnptoms 
being  followed  bj^  the  gradual  development  of  pain  at  the  right  costal 
margin  which  radiates  to  the  right  shoulder-blade.  At  times  the  pain 
is  so  severe  that  morphin  is  required.  There  is  no  pyrosis  or  vomiting 
and  no  loss  of  weight.  Some  tenderness  is  noted  in  the  right  ihac 
fossa ;  none  in  the  upper  abdomen.  Total  acidity  32 ;  free  16 ;  combined 
16.  Roentgen  examination:  Prepyloric  irregularity.  Tendency  to- 
ward hour-glass  form  (Fig.  101). 


Fig.  103. — Obliteration  of  pj-loric  segment  by  spasm.     Spastic  area  at  a. 

Second  examination,  four  days  later,  after  the  administration  of 
belladonna:  Irregularity  and  hour-glass  form  absent.  Stomach  and 
duodenum  negative  (Fig.  102).  The  deformity  of  the  stomach  in  this 
case  therefore,  was  quite  clearly  due  to  reflected  gastrospasm.  Find- 
ings at  operation:  Chronic  cholecystitis.  One  large  stone.  Appendix, 
negative.     Stomach  and  duodenum,  negative. 

Case  117,798.  Female,  aged  66  years.  In  the  past  fiA'e  years  the 
patient  has  had  many  attacks  of  hard  grinding  pain  in  the  right  abdo- 
men, radiating  downward,  and  which  comes  on  suddenly  and  lasts  up 
to  twelve  hours.     This  pain  is  accompanied  by  much  gas  and  bloating. 


KEPORT    OF    CASES  169 

For  four  years  soon  after  meals  she  has  had  daily  distress  in  the 
stomach,  with  sour  vomiting.  Former  weight  was  130  pounds;  pres- 
ent weight  105  pounds.  Total  acidity  24;  free,  16;  combined  8. 
Roentgen  examination:  Retention  of  half  the  six-hour  meal.  Prepy- 
loric narrowing  and  irregularity  (Fig.  96). 


Fig.  104. — Localized  spasm  of  greater         Fig.  105. — Same  case  as  in  Fig.   104. 
curvature.  Spasm  absent  at  second  examination. 


Fig.  106. — Spastic  irregularity,  pyloric  Fig.  107. — Marked  spasm  of  stomach, 

end.     Stomach  normal  at  operation.        pyloric    portion.       Operation;    stomach 

normal;  cancer  of  sigmoid. 

Without  giving  belladonna,  a  second  examination  was  made  and 
the  prepyloric  irregularity  was  found  still  present.  This  was  believed 
to  be  due  to  a  prepyloric  lesion.  As  the  sequel  shows,  the  case  illus- 
trates (1)  the  deforming  effect  of  reflected  spasm,  and  (2)  the  necessity 


170  GASTROSPASM 

of  giving  an  antispasmodic  before  reexamining.  Findings  at  opera- 
tion: Cholecystitis  with  multiple  papillomas  of  the  gall-bladder. 
Chronic  appendicitis.     Normal  stomach  and  duodenum. 

Case  106,124.  Male,  aged  70  years.  The  patient  has  had  inter- 
mittent diarrhea  for  six  months  and  in  the  early  part  of  this  period  had 
several  attacks  of  vomiting,  each  attack  lasting  a  day.  He  is  on  a 
rigid  diet  consisting  chiefly  of  beef  tea  and  toast.  When  this  is  not 
adhered  to,  he  occasionally  has  epigastric  pain.  At  times  there  is 
pain  in  the  lower  abdomen.  Weight  loss,  40  pounds.  Marked 
weakness.  Total  acidity  14;  free,  0;  combined  14.  Roentgen  exami- 
nation: No  retention  from  the  six-hour  meal.  Pars  pylorica  prac- 
tically obliterated;  the  pars  media  ending  in  an  irregular  stump. 
Diagnosis:  Cancer  (Fig.  103). 

The  tentative  clinical  diagnosis  was  disease  of  the  gall-bladder, 
but  in  view  of  the  pronounced  roentgen  findings  the  final  diagnosis 
was  cancer.  Findings  at  operation:  Large  septic  gall-bladder,  con- 
taining 8  ounces  of  bile  and  a  number  of  stones.  Marked  thickening 
of  pyloric  ring  due  to  spasm. 

In  this  instance  the  roentgen  examiner  should  ha^e  suspected  spasm 
for  the  following  reasons:  An  organic  lesion  of  the  size  indicated  in 
the  roentgenogram  should  have  produced  a  six-hour  retention  and  a 
degree  of  gastrectasia.  Neither  of  these  conditions  was  present. 
Further,  a  carcinomatous  growth  of  this  extent  and  in  this  situation 
would  undoubtedly  have  been  palpable  and  in  this  case  none  was  felt. 
Thus  there  were  at  least  three  very  good  reasons  for  a  reexamination 
after  the  administration  of  belladonna. 

REFERENCE 

1.  HoLZKNECHT,  G.  and  Luger,  A.:  "  Zur  Pathologie  und  Diagnostic 
des  Gastrospasmus."  Mitteilungen  a.  d.  Grenz.  der  Med.  u. 
Chir.,  1913,  xxvi,  669-694. 


CHAPTER  IX 
GASTRIC  CANCER 

In  the  detection  of  cancer  of  the  stomach,  the  roentgen-rays 
take  precedence  over  all  other  methods,  despite  the  fact  that 
''we  are  only  in  the  daguerreotype  stage  of  roentgen  photog- 
raphy."^ In  the  Mayo  Clinic,  95  per  cent,  of  gastric  cancers 
have  given  distinct  roentgenologic  signs  of  their  presence,  a 
percentage  not  approached  by  any  other  process  of  examination. 

Since  nearly  one-third  of  all  cancers  occur  in  the  stomach, 
and  since  early  recognition  and  operation  alone  afford  a  chance 
of  cure,  any  measure  which  will  increase  the  number  of  correct 
and  early  diagnoses  is  of  the  highest  importance. 

Prior  to  the  development  of  gastric  roentgenology,  reliance 
for  diagnosis  had  to  be  placed  upon  the  history,  the  physical 
examination  and  the  gastric  analysis.  Significant  in  the  history 
were:  middle  or  advanced  age  of  the  patient;  digestive  disturb- 
ance, such  as  anorexia,  vomiting,  occasionally  pain,  hemateme- 
sis,  etc.;  anemia,  cachexia  and  loss  of  weight.  By  the  physical 
examination  search  was  made  for  the  presence  of  a  tumor.  The 
gastric  analysis  was  scanned  for  achlorhydria,  food  remnants, 
blood,  and  Oppler-Boas'  bacilli. 

It  is  quite  clear  that  the  most  important  of  these  evidences 
can  result  only  from  a  cancer  that  is  well  advanced  or  obstruct- 
ive. The  records  of  our  clinic  show  that  in  a  large  series  of 
cases  confirmed  by  operation,  67  per  cent,  of  the  patients  had 
palpable  tumors  and  53.3  per  cent,  had  food  remnants.  In 
other  words,  33  per  cent,  had  no  palpable  tumors  and  46.7  per 
cent,  had  no  food  remnants  to  indicate  obstruction.  It  is  pre- 
cisely in  such  cases  as  these  that  the  roentgen-rays  have  their 
greatest  field  of  usefulness.     Indeed  it  is  no  longer  necessary  to 

171 


172  GASTRIC    CANCER 

wait  until  a  clinical  diagnosis  can  be  made  on  the  presence  of 
a  palpable  tumor,  food  remnants,  Oppler-Boas  bacilli,  etc. 

There  is  no  intent  to  say  that  the  clinical  data  should  be 
discarded.  On  the  contrary,  the  roentgenologist  should  be  ac- 
quainted with  the  clinical  facts  in  every  instance.  If  suggestive 
of  cancer,  they  will  stimulate  him  to  a  more  exhaustive  search. 
If  negative,  they  will  exercise  a  wholesome  restraint  upon  his 
interpretation  of  the  reflex  phenomena  so  often  produced  by 
conditions  outside  the  stomach.  More  important  still,  thfr 
final  diagnosis  should  be  compatible  with  all  the  findings,  if 
possible,  and  occasionally  only  their  correlation  will  make  the 
diagnosis.  A  combination  of  all  methods  forms  a  net  througk 
which  few  cancers  will  escape. 

It  must  be  conceded  that  the  carcinomatous  character  of 
tissue  can  be  determined  positively  only  by  the  microscope;  the 
roentgen-rays  can  show  merely  the  presence  of  a  gastric  tumor,, 
which  may  or  may  not  be  malignant.  However,  benign  gastric- 
neoplasms  are  uncommon;  according  to  Graham, ^  95  per  cent. 
of  tumors  of  the  stomach  are  cancer.  Further,  in  the  occasional 
instance  of  a  non-malignant  new-growth,  if  the  salient  features 
of  the  clinical  history  are  considered,  the  diagnostician  will  be 
at  least  suspicious  of  the  fact. 

The  roentgenologic  manifestations  of  gastric  cancer  include 
departures  from  the  normal  contour,  pyloric  action,  peristalsis, 
motility,  flexibility,  mobility,  position,  and  size  of  the  stomach. 
Enumerated  in  the  order  of  their  relative  importance,,  these- 
signs  are: 

1.  Filling-defects. 

2.  Alterations  of  pyloric  function: 

(a)  Gaping  of  the  pylorus. 

(b)  Obstruction  of  the  pylorus. 

3.  Perversion  of  peristalsis: 

(a)  Absence  of  peristalsis  from  involved  areas.. 

(b)  Weak  peristalsis. 

(c)  Antiperistalsis. 


FILLING    DEFECTS 


173 


(d)  Exaggerated  peristalsis. 

(e)  Irregular  peristalsis. 

4.  Altered  motility: 

(a)  Rapid  and  early  emptying  (non-obstructive  cases). 

(b)  Delayed  emptying  (obstructive  cases). 

5.  Lessened  flexibility. 

6.  Lessened  mobility. 

7.  Alteration  of  size  (capacity) : 

(a)  Shrinking. 

(b)  Dilatation. 

8.  Persistent  local  spasm. 

9.  Displacement. 

Filling-defects.- — The  filling-defect  is  the  basic  roentgeno- 
logic sign  of  cancer  and  practically  indispensable  to  a  positive 


Fig.   108.- — Small  encircling  cancer  at  the  pylorus.     Filling  defect  at  a. 


diagnosis.  It  is  occasioned  by  the  projection  of  the  tumor  into 
the  barium-filled  lumen  of  the  stomach,  thus  producing  irregu- 
larity of  contour.  At  the  stage  at  which  most  patients  first 
come  for  examination,  the  tumor  has  usually  attained  consider- 


174 


GASTRIC    CANCER 


Fig.   109. — Cancer  involving  entire  pyloric  segment. 


Fig.   110. — Same  case  as  in  Fig.  109. — Photograph  of  specimen  after  resection. 


FILLING- DEFECTS  175 

able  size,   and  the  filling-defect  is  sufficiently  extensive  to  be 
readily  seen. 

In  aspect,  filling-defects  vary  somewhat  according  to  the 
character  and  seat  of  the  neoplasm.  The  fungoid  cancer  often 
reveals  multiple  gross  irregularities,  gradually  shading  off  into 
the  barium  shadow  and  showing  the  elevations  and  depressions 
in  perspective. 


Fig.   111. — Central  filling  defect,  a,  caused  by  a  rounded  cancer-mass  projecting_into 

the  gastric  lumen. 

The  infiltrating  scirrhous  cancer  may  narrow  greatly  (though 
somewhat  regularly)  the  lumen  of  the  affected  portion,  which  is 
most  commonly  the  pyloric  end. 

A  small  cancer  encircling  the  pylorus  may  produce  a  broad- 
ening of  the  duodenopyloric  sulcus  or  a  conical  vestibule  (Fig. 
108).  A  more  extensive  cancer  may  seemingly  cut  off  the  entire 
pyloric  segment  (Figs.  109  and  110). 

High  up  in  the  pars  cardiaca  the  tumor  may  infringe  upon 
the  contour  of  the  gas-bubble  and  contrast  with  the  translucency 
of  the  latter.     If  the  esophageal  opening  is  involved,  obstruction 


176 


GASTRIC    CANCER 


of  the  esophagus  may  be  noted,  ^ith  backing  up  of  the  meal  and 
dilatation  of  the  gullet. 

A  tumor  on  the  anterior  or  posterior  wall  alters  the  contour 
in  the  obUque  or  sagittal  view;  in  the  anteroposterior  view  it 
may  show  centrally  as  a  less  dense  area  within  the  barium 
shadow  (Fig.  111). 

The  actuahty  and  permanence  of  filling-defects  cannot  be  de- 
termined T^ith  finahty  hj  a  few  roentgenograms  alone.  Essen- 
tial here   is  the  screen-examination,   during  which  the  gastric 


Fig.   112. — Filling  defects  in  pyloric  and  mid  portions  of  stomach. 

shadow  can  be  studied  at  various  angles  by  turning  the  patient, 
and  observation  can  be  made  of  the  effect  of  active  and  passive 
movements. 

A  true  filUng-def  ect  is  permanent,  showing  no  change  in  loca- 
tion or  appearance  after  palpatory  manipulation,  after  adminis- 
tration of  antispasmodics,  or  upon  reexamination. 

Absence  of  peristalsis  from  the  suspected  area  is  strongh^  con- 
firmatory. 

The  correspondence  of  a  filUng-defect  to  a  palpable  mass  is 


FILLING-DEFECTS 


177 


Fig.   113. — Cancer  in  upper  cardia.     Filling  defect  at  a. 


Fig.   114. — Exclusion  of  barium  from  prepyloric  region,  a,  by  small  obstructing  cancer. 
12 


178 


GASTRIC    CANCER 


indicative  of  its  genuineness.  Tumor-masses  that  elude  detec- 
tion at  the  physical  examination  are  sometimes  felt  by  the  roent- 
genologist. Descent  of  the  mass  into  a  region  where  it  may  be 
palpated  is  favored  by  the  upright  posture,  and  the  shadowed 
gastric  outline  enables  the  examiner  to  palpate  a  specific  area 
with  greater  exactness. 

Unevenness  of  outline  and  lack  of  symmetry  are  rather  con- 
stant in  true  filling-defects. 


t07CQl 


Fig.  115. — Hour  glass  stomach  of  cancer.     Constriction  and  irregularity 
of  contour  at  a. 

Filling-defects  in  the  pars  media  or  pars  pylorica  (Fig.  112) 
are  less  likely  to  be  overlooked  than  those  in  the  pars  cardiaca. 
A  filling-defect  well  up  in  the  fundus  may  be  brought  into  better 
relief  by  pressing  the  barium  upward,  or  by  screening  and  plating 
with  the  patient  in  the  recumbent  position  (Fig.  113).  With  the 
patient  standing,  small  filling-defects  in  the  pars  pylorica  also 
require  careful  study  for  detection,  owing  to  the  difficulty  of  ob- 
taining a  clear  outline  of  this  region  because  of  its  proximity  to 
the  spine,  and  the  tendency  of  the  barium  to  settle  away  from  the 
pylorus  of  a  fish-hook  stomach  (Fig.  114).     A  small  defect,  well 


SIMULANTS     OF    FILLING-DEFECTS  179 

seen  in  the  partly  filled  stomach,  may  be  concealed  in  the  dis- 
tended stomach.  Hence,  observation  should  be  made  during  the 
process  of  ingestion  as  well  as  after  repletion.  The  tube-box 
diaphragm  should  be  actively  employed  while  screening  and  the 
aperture  narrowed  to  increase  the  distinctness  of  small  suspected 
areas,  thus  facilitating  close  scrutiny. 

Filling-defects  situated  in  the  pars  media  occasionally  pro- 
duce hour-glass  deformity  (Fig.  115).  More  commonly  such  an 
hour-glass  is  of  the  X-type  in  contradistinction  to  the  usual 
B-type  of  gastric  ulcer  or  spasm,  though  this  distinction  is  not 
invariable.  As  a  rule,  the  hour-glass  of  cancer  lacks  the  sharp 
definition  of  the  hour-glass  of  ulcer  or  spasm,  and  shows  an  indefi- 
nite shading  off. 

Filling-defects  from  Causes  Other  Than  Cancer. — Filling-de- 
fects, either  apparent  or  real,  may  be  produced  by  numerous 
conditions  other  than  cancer.  Apparent  filling-defects  may  re- 
sult from  the  use  of  faulty  media;  secretion  in  the  stomach;  food 
remnants;  hair-ball;  gas  or  fecal  matter  in  the  colon;  barium  in 
the  bowel  adjacent  to  the  stomach ;  lordosis  and  scoliosis ; pressure 
of  the  stomach  against  the  spine;  pressure  of  a  deformed  costal 
arch;  strong  retraction  of  the  upper  abdominal  wall;  spasm; 
adhesions  from  perigastric  inflammations;  extrinsic  tumors; 
displacement  and  distortion  of  the  stomach  by  ascites,  ovarian 
cysts,  pregnancy,  etc.  Actual  filling-defects,  not  distinguish- 
able of  themselves  from  those  of  cancer,  may  be  caused  by  vari- 
ous benign  tumor-producing  lesions  of  the  stomach. 

Faulty  media  in  which  the  barium  is  unevenly  distributed 
may  give  varying  degrees  of  opacity  in  the  gastric  shadow  and 
thus  imitate  filling-defects.  The  mixture  may  be  too  stiff, 
poorly  mixed,  or  an  insufficient  quantity  of  barium  maybe  used. 
With  very  thin  mixtures  the  barium  often  settles  to  the  lower 
pole,  leaving  the  upper  gastric  lumen  unvisualized.  A  little 
palpatory  shifting  of  the  gastric  contents  readily  shows  the 
character  of  these  pseudo-defects,  and  erroneous  interpretation 
is  not  likely  to  occur  unless  an  attempt  is  made  to  base  a  diagnosis 
upon  plates  alone. 


180  GASTRIC    CANCER 

Sometimes  secretion  is  imprisoned  in  the  pyloric  end  of  a 
fish-hook  stomach,  showing  as  a  clear  area  above  the  opaque 
meal.  The  straight  horizontal  line  of  demarcation  between  the 
secretion  and  the  barium  is  indicative  of  the  artificial  nature  of 
the  defect.  By  palpatory  pressure  the  secretion  can  be  dis- 
placed by  the  meal,  or  passed  into  the  duodenum. 

Food  masses  in  the  stomach,  by  excluding  the  barium  from 
the  area  in  which  they  lie,  may  simulate  filling-defects.  Here 
palpatory  shifting  of  the  gastric  contents  will  cause  the  seeming 
defect  to  change  its  situation  or  disappear.  However,  as  a  mat- 
ter of  routine,  patients  should  be  examined  only  in  the  fasting 
condition.  Employment  of  the  tube  to  withdraw  food  rem- 
nants in  cases  of  pyloric  stenosis  should  be  resorted  to  unless 
otherwise  contraindicated. 

Occasionally  a  hair-ball  is  found  in  the  stomachs  of  neurotic 
persons  who  are  addicted  to  biting  the  hair.  The  accumulation 
may  be  a  rounded  ball,  or  may  form  a  complete  cast  of  the  gas- 
tric cavity.  In  either  event,  after  giving  the  bariumized  meal 
the  peripheral  gastric  contour  will  be  shown  fairly  well.  If  the 
hair-ball  is  small  it  will  show  as  a  central  area  of  diminished  den- 
sity somewhat  like  the  filling-defect  produced  by  a  cancer  on  the 
anterior  or  posterior  wall.  The  ball  may  be  shifted  about  by 
palpation  or  even  displaced  upward  into  the  gas-bubble.  If  the 
entire  stomach  is  filled  by  the  hair-mass,  the  gastric  shadow  will 
show  peculiar  streaking  and  mottling  throughout. 

Gas  in  the  colon  is  a  source  of  annoyance.  Even  after  prepa- 
ration of  the  patient  by  purging  there  is  usually  more  or  less 
gas  in  the  splenic  flexure.  Frequently  the  distention  is  sufficient 
to  infringe  upon  the  greater  curvature  and  produce  considerable 
deformity.  Such  irregularities  ought  not  to  be  very  deceptive, 
as  they  change  with  manipulation,  and  the  distention  of  the 
transparent  haustrated  loop  of  intestine  is  rather  obvious  (Fig. 
116).  Rarely,  the  transverse  colon  may  be  displaced  upward 
and  lie  directly  across  the  stomach.  Its  course  may  be  traced 
by  its  transparency  and  haustration.  Fecal  matter  in  the  bowel 
also  may  cause  indentations  in  the  adjacent  gastric  contour. 


SIMULANTS    OF    FILLING-DEFECTS  181 

Deformities  of  the  dorsal  and  lumbar  spine,  including  lordo- 
sis and  scoliosis,  which  may  deform  the  contiguous  gastric  con- 
tour, are  rather  manifest  and  rare. 

Pressure  of  the  stomach  against  the  spine,  either  normal  or 
with  well-marked  physiologic  lordosis,  often  disfigures  the  trans- 
spinal  portion  of  the  stomach.  This  disfigurement  is  seen  often 
on  plates   made  with  the   patient's   abdomen  pressed  tightly 


Fig.   116. — Gas  in  colon  causing  pseudo-filling-defect  at  a. 

against  the  cassette  (Figs.  117  and  118).  Not  rarely  it  is  ob- 
served also  during  roentgenoscopy,  especially  when  the  patient 
maintains  a  high  degree  of  abdominal  rigidity  and  tension. 
These  pseudo-defects  can  be  avoided  by  encouraging  the  patient 
to  relax  his  abdomen  during  the  screen-examination,  and  by 
supporting  the  hips  and  shoulders  when  making  plates  in  the 
prone  position. 

Strong  retraction  of  the  belly-wall  sometimes  occasions  a 
wide,  regularly  curved  depression  in  the  greater  curvature  of  the 


182 


GASTRIC   CANCER 


Fig.  117. — Deforming  effect  of  pressure  against  the  spine.     The  rugse  of  the^stomach 
can  be  seen  in  the  distorted  area. 


Fig.   118. — Gross  deformity  of  mid  portion  of^stomach  due  to  pressure  against  the 

spine. 


SIMULANTS     OF    FILLING-DEFECTS 


183 


stomach  just  below  the  left  costal  arch.  Its  smooth,  sharp  out- 
line and  its  situation  should  differentiate  it  from  an  actual 
filling-defect  (Fig.  119). 

Spasm  of  the  gastric  musculature  may  produce  very  de- 
ceptive imitations  of  the  filling-defects  caused  by  cancer.  Mi- 
grating or  intermittent  spastic  contractions  which  are  seen 
frequently,  are  evidently  spasmodic  because  of  their  changing 
situation  or  interruption;  but  spasm  is  not  always  migratory  or 
intermittent.     Often  a  non-moving,  spastic  incisura  will  indent 


Fig.   119. — Incurvation  of  the  greater  curvature  at  the  left  costal  arch, 
seen  in  thin  persons  with  tense  abdominal  walls. 


This  is  often 


the-stomach  so  as  to  form  an  hour-glass,  exactly  simulating  an 
organic  hour-glass  stomach.  In  other  cases  the  entire  pyloric 
portion  of  the  stomach  may  be  constricted  to  a  stiff,  narrow  tube, 
rolling  under  the  palpating  fingers  as  a  cylindrical  mass.  Again, 
the  entire  stomach  may  be  spastically  contracted,  small,  and  un- 
even, without  definite  peristalsis.  In  all  the  above  conditions  the 
outline^of  the  stomach,  though  not  regular,  is  sharply  defined, 


184  "  GASTRIC    CANCER 

and  this  circumstance  should  put  the  observer  on  guard.  How- 
ever, there  is  still  another  variety  of  spasm  which  is  dangerously 
misleading;  in  this  form  the  barium  shadow  in  the  spastic  area, 
which  may  be  large  or  small,  fades  off  toward  the  gastric  per- 
iphery, exactly  as  though  intruded  upon  b}^  a  tumor-mass.  The 
spasm  may  sometimes  be  effaced  by  massage  during  the  screen- 
examination,  but  as  a  rule  it  reappears.  If  accessible  to  palpa- 
tion, the  absence  of  a  tumor  from  the  suspected  region  should 
suggest  cautious  interpretation.  The  pyloric  portion  of  the 
stomach  is  a  common  seat  of  this  spastic  deformity. 

The  points  of  difference  between  true  filling-defects  and  those 
l^roduced  by  spasm  can  be  summed  up  as  follows : 

The  true  defect  is  permanent,  often  corresponds  to  a  pal- 
pable mass  if  accessible,  and  is  not  often  sharply  delineated. 

The  spastic  filling-defect  is  often  migratory  or  transient  and 
is  frequently  sharp  in  outline;  the  contracted  muscle  is  rarely 
palpable.  Spasm  may  disappear  upon  distracting  the  attention 
of  the  nervous  patient  thereby  causing  him  to  relax  his  abdomen, 
or  by  Adgorous  palpatory  manipulation.  Also,  it  may  disappear 
or  change  its  situation  at  a  second  examination.  In  many  cases 
reexamination  after  the  administration  of  an  antispasmodic  is 
necessary.  Belladonna,  atropin,  and  papaverin  are  the  drugs 
employed  most  generally  (see  Gastrospasm).  Physiologic 
effects  from  the  drug  must  be  obtained,  and  large  doses  may 
be  necessary.  This  procedure  should  never  be  omitted  in  any 
case  in  w^hich  the  possible  existence  of  spasm  cannot  absolutely 
be  eUminated.  In  rare  instances  spasm  may  persist  in  spite 
of  this  measure,  but  such  cases  are  quite  uncommon. 

Rarely,  adhesions  from  perigastric  inflammations  may  pro- 
duce distortions  resembling  the  filling-defects  of  cancer.  The 
inflammatory  process  originates  most  commonly  from  perforat- 
ing gastric  ulcer  or  from  pericholecystitis.  A  perforating  gas- 
tric ulcer  in  the  pars  media,  producing  perigastric  adhesions,  is  apt 
to  reveal  its  identity  by  a  pocket,  a  niche,  or  an  incisura.  Per- 
forating ulcer  in  the  pars  pylorica  may  be  less  characteristic 
and  fairly  difficult  to  distinguish  from  cancer. 


'simulants    of    FILLINGf-DEFECTS  185 

Tumors  extrinsic  to  the  stomach  that  deform  its  contour 
may  originate  in  the  liver,  spleen,  pancreas,  kidney,  large  or 
small  bowel,  omentum,  mesentery,  or  belly-wall.  As  a  rule, 
the  filling-defect  occasioned  by  their  thrust  into  the  gastric  lumen 
is  usually  smoothly  rounded,  the  inequalities  of  the  tumor  being 
covered  by  the  wall  of  the  stomach  (Fig.  120).  Unless  these 
tumors  are  adherent  to  the  stomach,  which  is  not  usual,  changes 


Fig.   120. — Gastric   contour   deformed  by   an   extrinsic   tumor — pancreatic   cyst. 

of  position  of  the  stomach  with  respiration  or  by  palpation  will 
alter  the  location  of  the  filling-defect.  In  such  cases,  also,  the 
peristalsis  is  usually  normal,  and  this  fact  contraindicates  a 
tumor  of  the  stomach  itself. 

The  stomach  may  be  eccentrically  distorted  and  displaced 
by  ascites,  ovarian  cysts,  and  other  large  abdominal  tumors, 
pregnancy,  or  even  by  a  tensely  retracted  abdominal  wall. 
Such  conditions  should  be  rather  patent. 

Sarcoma,  tumor  masses  produced  by  syphilis  and  benign 
neoplasms,  as  well  as  varicosities  of  the  gastric  veins,  may  cause 
filling-defects  practically  identical  with  cancer.     These  condi- 


186 


GASTEIC   CANCER 


tions  are  so  unusual  that  the  roentgenologist  should  not  be  un- 
duly alert  for  them.  If  syphilis  is  suspected,  the  Wassermann 
test  should  be  applied. 

Alteration  of  Pyloric  Function. — In  cancer  the  pyloric  func- 
tion may  be  perverted  in  either  one  of  two  quite  opposite  ways, 
namely,  either  by  gaping  or  obstruction.  The  barium  water 
often  flows  through  a  normal  pylorus,  with  little  or  no  inter- 


FiG.  121. — Gaping  pylorus  in  a  case  of  gastric  cancer.  Note  quantity  of  barium 
in  duodenum  and  upper  small  bowel.  This  stomach  emptied  itself  of  the  opaque  meal 
in  a  very  few  minutes.  The  filling  defect  of  the  cancer  is  seen  in  the  cardiac  portion  of 
the  stomach. 


ruption,  but  as  soon  as  the  thicker  pap  is  given  the  flow  usually 
becomes  less  free  and  intermittent.  The  gaping  pylorus  of 
cancer  is  characterized  by  a  free  and  continuous  exit  of  both  mix- 
tures into  the  intestine.  Very  commonly  the  stream  is  volumi- 
nous and  the  upper  small  bowel  is  speedily  filled  with  the  opaque 
mixture  (Fig.  121).  The  stomach  may  be  almost  or  even  com- 
pletely emptied  during  the  brief  period  of  examination. 

Gaping  of  the  pylorus  results  from  an  interference  with  its 
sphincteric  contraction,  either  by  infiltration  and  stiffening  of 


ALTERATION    OF    PYLORIC    FUNCTION 


187 


Fig.  122. — Six-hour  retention,  a,  in  a  case  of  pyloric  cancer. 


Fig.  123. — Same  case  as  in  Fig.  122;  stomach  filled.     Prepyloric  filling  defect  at  a. 


188  GASTRIC    CANCER 

the  muscular  ring  or  by  an  absence  of  the  pylorus-closing  reflex. 
Thus  it  is  seen  quite  typically  in  scirrhous  cancer  involving  the 
pars  pylorica,  but  is  found  also  in  association  with  cancers  of 
the  cardia  or  media,  either  scirrhous  or  medullary.  A  free  and 
continuous  flow  somewhat  similar  to  that  seen  with  the  gaping 
pylorus  of  cancer  may  be  found  in  other  conditions,  such  as 
duodenal  ulcer,  gall-bladder  disease  (with  or  without  adhesions), 
achylia,  certain  diarrheas,  and  sometimes  even  in  chronic  ap- 
pendicitis. It  should  be  said,  however,  that  in  these  conditions 
the  flow  as  a  rule  is  less  voluminous  than  that  noted  typically 
in  cancer. 


ty  /i 


Fig.   124. — Photograph  of  resected  specimen  from  case  shown  in  Fig.  123. 

Pyloric  obstruction,  as  evidenced  by  a  six-hour  residue  in 
the  stomach,  occurs  in  about  60  per  cent,  of  gastric  cancers — - 
often er  than  with  any  other  lesion.  The  amount  of  residue 
varies  with  the  degree  of  obstruction  (Figs.  122,  123  and  124). 
It  is  noteworthy  that  the  lumen  of  the  pyloric  canal  may  be 
considerably  diminished  by  the  intrusion  of  a  cancer  without 
resulting  in  a  six-hour  residue,  for  the  reason  that  the  lessened 
caliber  is  compensated  by  the  lack  of  sphincteric  control.  Since 
numerous  causes  other  than  cancer  may  operate  to  produce  a 
six-hour  gastric  retention,  the  Dresence  of  a  residue  should  not 


PERISTALSIS  189 

be  given  undue  weight  in  making  the  final  diagnosis,  but  its 
occurrence  should  stimulate  a  careful  search  for  filling-defects 
and  other  evidences  of  cancer. 

Peristalsis. — The  perversions  of  peristalsis  resulting  from 
gastric  cancer  are  varied.  Absence  of  peristalsis  from  a  can- 
cerous area  of  the  gastric  wall  due  to  local  loss  of  muscular  con- 
tractility is  a  valuable  sign.  In  some  such  instances  a  wave 
may  progress  to  the  affected  site,  skip  it,  and  take  up  its  course 
again  beyond,  and  this  observation  is  one  test  for  the  genuine- 
ness of  cancerous  filling-defects.  "Weak  peristalsis,  the  waves 
being  both  shallow  and  infrequent,  is  fairly  common  in  cancer. 
Frequently  the  stomach  seems  to  be  perfectly  inert.  Anii- 
peristalsis  is  occasionally  observed  in  cancer  with  pyloric  ob- 
struction. The  antiperistaltic  waves  are  best  seen  on  the  greater 
curvature  in  the  pars  pylorica  and  media.  The  waves,  though 
sometimes  deep,  are  usually  wide  and  shallow.  Beginning  at 
the  pylorus,  they  sweep  slowly  backward  and  disappear  in  the 
upper  pars  media.  They  may  coexist  with  peristaltic  waves 
traveling  in  the  normal  direction.  Exaggerated  peristalsis,  as  a 
sequence  of  cancer  with  pyloric  obstruction,  is  more  rare  than 
might  reasonably  be  supposed.  When  seen,  the  exaggeration  is 
usually  more  marked  on  the  greater  curvature.  It  may  be  irreg- 
ular as  to  the  depth  and  succession  of  the  waves;  a  fairly  deep 
wave  may  be  closely  followed  by  a  shallow  one,  while  the  next 
may  be  normal  as  to  depth  and  rhythm.  None  of  the  foregoing 
perversions  of  peristalsis  is  peculiar  to  cancer,  and  they  are 
merely  indicative  of  a  pathologic  process. 

Altered  Motility. — Emptying  of  the  cancerous  stomach  may 
be  either  retarded  or  accelerated,  according  to  the  presence  or 
absence  of  pyloric  obstruction.  In  the  non-obstructive  cases 
hypermotility  is  the  rule,  and  is  a  natural  sequence  of  the  achylia 
and  gaping  pylorus.  The  acceleration  of  gastric  clearance  may 
be  extreme  and  the  stomach  evacuate  itself  with  extraordinary 
rapidity.  The  acceleration  is  exhibited  often  not  only  in  a  rapid 
and  early  clearance  of  the  stomach,  but  also  in  an  advanced  posi- 
tion of  the  six-hour  meal,  the  head  of  the  barium  column  appear- 


190  GASTRIC    CANCER 

ing  in  the  transverse  colon,  the  splenic  flexure,  the  descending 
colon,  or  even  the  ampulla.  In  the  obstructive  cases,  delayed 
clearance  is  shown  by  the  six-hour  residue.  That  portion  of  the 
meal  which  has  passed  through  into  the  intestine  may  or  may 
not  show  retarded  progress.  It  is  to  be  remembered  that  gastric 
motility  may  be  affected  by  many  things  other  than  cancer. 
HypermotiUty  of  moderate  degree  is  a  common  result  of  non- 
obstructive duodenal  ulcer,  achylia,  and  diarrheic  conditions, 
Hypomotihty,  with  or  without  a  six-hour  retention,  may  result 
from  any  sort  of  organic  obstruction  at  the  pylorus  or  near  Tdb- 
yond,  or  from  reflex  pylorospasm. 

Lessened  Mobility. — Exceptionally,  when  it  involves  adjacent 
structures,  a  cancer  produces  more  or  less  fixation  of  the  stomach. 
The  attachment  may  be  to  the  abdominal  wall,  or  to  the  liver, 
pancreas,  or  other  viscera.  The  presence  of  fixation  may  be  de- 
termined sometimes,  but  not  always,  by  palpatory  maneuvers, 
depending  upon  the  position  of  the  stomach,  the  situation  of  the 
attachment,  and  the  degree  of  laxity  of  the  abdominal  wall,  and, 
also,  b}^  observation  during  forced  respiration.  The  small,  high- 
lying,  contracted  stomach,  inaccessible  to  manipulation,  may 
appear  to  be  fixed  but  is  not  necessaril}^  so.  On  the  other  hand, 
a  stomach  which  has  a  free  and  flexible  lower  pole  may  seem  to 
be  freeh"  mobile  when  there  are  definite  adhesions  on  the  lesser 
curvatm'e.  Inasmuch  as  fixation  is  simply  an  indication  of 
extra-gastric  involvement,  it  is  merely  a  contributory  sign  of 
cancer.  It  may  be  taken  into  account  in  estimating  the  possi- 
bihty  of  resection. 

Lessened  Flexibility. — Diminished  flexibility  of  the  cancer- 
ous gastric  wall  is  a  practicable  and  useful  sign,  especially  of 
scirrhous  cancer.  Upon  narrow  j)alpation,  as  with  the  finger 
tips,  the  accessible  normal  gastric  wall  will  show  corresponding 
indentation,  whereas  if  stiffened  hj  infiltration  it  will  either  be 
disproportionately  indented  or  moved  aside  en  masse.  The  loss 
of  pliability  may  be  somewhat  evident  also  by  the  lack  of  con- 
tour-change during  deep  respiration  or  during  the  process  of 
filhng  the  stomach,  the  lumen  of  the  involved  area  being  almost 


PEKSISTENT  LOCAL  SPASM  191 

constant  in  size  at  all  degrees  of  repletion,  while  the  unaffected 
portion  expands  to  accommodate  the  increased  volume. 

Persistent  Local  Spasm. — A  cancer  on  the  lesser  curvature 
may  give  rise  to  a  spastic  indrawing  on  the  opposite  curvature. 
Often  it  is  quite  broad  and  has  been  spoken  of  as  the  ''broad 
incisura"  of  cancer  as  compared  with  the  relatively  narrow  in- 
cisura  of  ulcer.  Besides  the  ''broad  incisura,"  the  deformity 
produced  by  the  growth  itself  is  commonly  observable.  We 
have  seen  exceptional  cases,  however,  in  which  an  incisura  from 
cancer  was  narrow,  resembled  a  typical  ulcer-incisura,  and  was 
the  only  demonstrable  roentgenologic  sign  of  the  lesion.  Such 
spasm  may,  of  course,  be  imitated  by  spasm  from  extrinsic 
causes,  and  careful  differentiation  may  be  necessary.  Again,  an 
occasional  case  of  gastric  cancer  will  be  seen  in  which  a  shifting, 
more  or  less  diffuse,  spasm  is  the  only  evidence  obtainable,  and  a 
diagnosis  is  impossible. 

Altered  Size  and  Capacity. — A  common  feature  of  the  can- 
cerous stomach  is  marked  diminution  of  the  capacity  and  appar- 
ent size.  The  reduction  may  be  the  result  either  of  the  projec- 
tion of  large  fungoid  masses  into  its  lumen  or  the  shrinking  effect 
of  scirrhous  infiltration.  In  extreme  instances,  the  effort  to 
accommodate  the  ingesta  causes  a  backing  up  of  the  meal  in  the 
esophagus,  which  latter  may  show  dilatation.  Besides  cancer, 
other  causes  that  may  lessen  the  capacity  of  the  stomach  are 
perforating  ulcer,  with  extensive  perigastritis,  spasm,  and  benign 
lesions.  The  upper  loculus  of  an  hour-glass  stomach  may  be 
mistaken  for  a  contracted  stomach  if  the  presence  of  the  lower 
loculus  be  overlooked.  On  the  other  hand,  an  obstructive  can- 
cer at  the  pyloric  end  may  result  in  considerable  dilatation  of 
the  stomach.  A  similar  dilatation  may  be  consequent  upon 
other  obstructive  causes.  It  follows,  then,  that  neither  large 
nor  small  size  of  the  stomach  is  especially  significant  of  cancer, 
but  that  marked  variation  in  size  of  the  stomach  is  at  least  sug- 
gestive of  the  presence  of  a  lesion. 

Displacement. — The  predilection  of  cancer  for  the  pyloric 
end  of  the  stomach,  often  with  more  or  less  complete  obliteration 


192  GASTRIC    CANCER 

of  the  distal  portion  of  its  lumen,  results  frequently  in  an  appar- 
ent displacement  of  the  stomach  to  the  left,  since  its  proximal 
portion  only  is  visualized.  Aside  from  this,  however,  in  cases 
of  scirrhous  cancer,  there  may  be  actual  displacement  upward 
and  to  the  left.  Somewhat  similar  displacements  may  occur  as 
a  result  of  perforating  ulcer,  ascites,  tumors  outside  the  stom- 
ach, and  retraction  of  the  abdominal  wall. 

Pathology. — With  the  microscopic  pathology  of  gastric  can- 
cer the  roentgenologist  has  little  concern,  but  the  roentgenologic 
appearances  of  cancer  sometimes  depend  quite  considerably 
upon  its  character  as  affecting  its  form,  location,  and  extent. 
Hence,  a  few  statements  concerning  certain  anatomical  varieties 
of  cancers  and  their  gross  aspects  may  assist  in  clarifying  the 
description  of  this  lesion  as  seen  by  the  roentgen-rays. 

Cancers  of  the  stomach  invariably  originate  in  the  mucous 
layer.  While  basically  they  are  all  epithelial  neoplasms,  they 
present  numerous  structural  differences.  Disregarding  those 
variations  which  are  here  unimportant,  there  are  three  forms 
which  are  of  chief  interest  from  a  radiologic  standpoint : 

1.  A  proliferative  form,  almost  wholly  epithelioid  in  compo- 
sition, with  circumscribed  tumor  production.  This  is  the 
fungous  type  with  which  may  be  included  for  present  conven- 
ience the  medullary  (encephaloid),  cauliflower  and  adenocar- 
cinomas. It  is  characterized  by  a  relatively  small  amount  of 
interstitial  tissue,  and  hence  is  soft. 

2.  An  infiltrative  form.  This  is  the  scirrhous  type.  Speak- 
ing in  a  general  way,  it  infiltrates  the  gastric  wall  with  less  un- 
evenness  of  contour  and  less  projection  into  the  cavity  of  the 
stomach  than  the  fungous  type.  It  is  characterized  by  a  rela- 
tively large  amount  of  interstitial  tissue,  and  is  hard  and  more 
frequently  associated  with  ulceration  than  the  other  types.  The 
infiltration  may  be  either  localize?f*or  general. 

When  localized,  the  pyloric  end  of  the  stomach  or  the  lesser 
curvature  is  the  part  most  commonly  affected. 

The  general  diffuse  infiltration  may  involve  a  large  part  or 
the  whole  of  the  stomach,  which  is  thick-walled  and  contracted. 


PATHOLOGY 


193 


Fig.  125. — Filling-defects  produced  by  fungous  carcinoma,  shown  in  Fig.  126. 


Fig.   126. — Photograph  of  specimen,  showing  fungous  (medullary)  tj-pe  of  cancer. 
The  rounded  mass  at  a  corresponds  to  the  circular  filling  defect  in  the  roentgenogram, 
Fig.  125. 
13 


194  GASTRIC    CANCER 

This  is  regarded  by  many  as  identical  with  the  so-called  'feather- 
bottle"  stomach,  or  ''diffuse  fibrosis." 

3.  A  degenerative  form,  the  so-called  "colloid,"  or,  more 
correctly,  "mucoid"  cancer.  In  this  form  the  cells  lose  their 
structure  and  become  merged  into  a  homogeneous  mucoid  mass. 
Mucoid  degeneration  may  occur  in  either  the  fungous  or  scir- 
rhous type. 

Roentgen  Characteristics  of  Fungous  Cancer. — In  abroad  way 
the  typical  fungous  cancer  shows  the  following  characteristics: 

1.  It  does  not  decrease  the  size  of  the  stomach  as  a  whole. 
While  the  capacity  of  the  stomach  may  be  somewhat  lessened 
by  the  encroachment  of  the  mass  upon  its  lumen,  the  gastric 
dimensions  are  not  otherwise  diminished.  Often  the  hook-form 
is  preserved  (Figs.  125  and  126). 

2.  Occasionally  it  involves  the  greater  curvature  only,  espe- 
cially of  the  body  of  the  stomach  (Fig.  127). 

3.  The  involved  portion  of  the  gastric  wall  is  sharply  delim- 
ited from  the  uninvolved  portion. 

4.  Sometimes  it  produces  large,  multiple,  irregular  filling- 
defects  projecting  into  the  gastric  lumen  and  shading  gradually 
into  the  central  barium  shadow,  somewhat  resembling  finger- 
prints upon  paraffin  (Fig.  128). 

5.  If  situated  at  the  pyloric  end  this  type  is  likely  to  produce 
obstruction. 

Roentgen  Characteristics  of  Scirrhous  Cancer. — Typical  ad- 
vanced scirrhous  cancer  may  be  recognized  by: 

1.  Its  marked  shrinking  effect  upon  the  stomach.  The 
capacity  of  the  stomach  is  not  merely  lessened  by  a  filling-defect, 
but  is  greatly  diminished  by  the  loss  of  expansibility  due  to 
widespread  infiltration  as  well  as  actual  contraction. 

2.  Frequent  inA'olvement  of  the  pyloric  end  and  lesser  curva- 
ture. Quite  commonly  a  scirrhus  completely  encircles  the  py- 
loric end  and  the  deformity  thus  produced  gives  the  stomach 
some  resemblance  to  a  curved  funnel  or  an  Indian  pipe.  The 
barium  projects  into  the  canalized  pyloric  mass  as  a  smooth  or 
slightly  irregular  spicule. 


ROENTGEN  CHARACTERISTICS   OF  FUNGOUS   CANCER         195 


Fig.  127. — Irregular  filling  defect,  greater  curvature,  body  of  stomach,   at  a,  due  to 

fungous  cancer. 


Fig    128.- — Finger-print-like  filling  defects  of  fungous  cancer. 


196  GASTRIC   CANCER 

3.  Gradual  merging  of  involved  into  non-involved  portion 
of  the  gastric  wall.  The  limits  of  the  lesion  are  difficult  or  im- 
possible to  determine  radiologically.  The  lesion  is  usually  more 
extensive  than  the  picture  indicates. 

4.  The  filling-defects  of  scirrhous  cancer  are  commonly  less 
grossly  irregular  than  those  of  the  fungous  type  (Figs.  129  and 
130). 

5.  This  type  of  cancer,  even  though  involving  the  pars 
pylorica,  is  likely  to  show  a  gaping  pylorus,  although  it  may 
produce  obstruction. 

Mucoid  Cancer. — A  markedly  diminished,  fairly  regular 
central  lumen  surrounded  by  a  thick-walled  tumor-mass  is 
sometimes  seen  in  extensive  mucoid  degeneration,  but  mucoid 
change  can  rarely  be  even  surmised  by  the  radiologic  appear- 
ances. It  gives  practically  the  same  screen  and  plate  picture 
as  the  scirrhous  form. 

It  will  be  understood  that  the  three  forms  mentioned  do 
not  always  or  necessarily  exist  independently  of  each  other, 
that  the  classification  and  descriptions  are  practical  rather  than 
accurate,  and  that  differentiation  of  these  forms  is  not  always 
easy.  Sometimes  these  pathologic  differences  in  gastric  can- 
cers are  sufficiently  manifest  in  the  roentgenologic  picture  to 
warrant  an  opinion  as  to  their  probable  nature.  However,  such 
an  opinion  should  be  advanced  with  caution,  and  then  only  in 
those  rather  few  cases  which  are  typical,  for,  in  the  majority 
of  cases,  the  roentgenologist  had  better  be  content  with  a  diag- 
nosis of  cancer  without  attempting  to  specify  the  particular 
variety. 

Carcinomatous  Ulcer. — While  by  far  the  greater  number  of 
gastric  cancers  manifest  themselves  frankly  as  tumors  at  the 
time  the  patients  present  themselves  for  examination,  ulcers 
are  found  occasionally  which  show  microscopic  evidence  of 
malignancy.  In  their  gross  characteristics  and  roentgenologic 
appearances  these  ulcers  are  not  usually  different  from  benign 
ulcers.  In  most  instances  the  crater  of  the  ulcer  is  visualized 
as  a  niche  projecting  from  the  gastric  lumen.     This  may  or 


SCIRRHOUS    CANCER 


197 


Fig.   129.- — Uniform,  wedge-like  prepyloric  narrowing  at  a,  in  a  case  of  scirrhous  cancer. 

See  specimen  Fig.  130. 


Fig.  130. — Photograph  of  resected  pyloric  end  of  stomach.     Scirrhous  cancer. 


198  GASTRIC    CANCER 

may  not  be  associated  with  hour-glass  stomach,  an  incisiira, 
or  six-hour  retention.  The  only  suspicious  feature  sometimes 
shown  by  the  roentgen-rays  is  the  extraordinarily  large  size  of 
the  ulcer  crater.  In  a  few  of  our  own  cases  in  which  the  niche 
was  3  or  4  cm.  broad  the  ulcer  was  found  on  microscopic  exami- 
nation to  be  malignant  (Fig.  131). 


Fig.   131. — Very  large  ulcer-crater  at  a.     Malignant. 

Operability. — In  deciding  the  question  of  operation  in  a 
given  case  of  cancer  the  roentgen-rays  furnish  information  of 
great,  often  decisive,  importance.  Primarily,  operability  de- 
pends considerably  upon  the  skill  of  the  operating  surgeon:  but 
aside  from  this,  certain  radiologic  findings  speak  for  or  against 
operation,  whether  radical  or  palliative.  The  location,  extent, 
and  character  of  the  cancer  are  all  matters  of  fundamental  im- 
portance. Growths  involving  the  cardia  or  upper  media  are 
not  accessible  to  resection  (Fig.  132),  while  those  at  the  pyloric 
end  (Fig.  133)  or  lower  media  are  often  resectable.  Obviously, 
resectability  depends  also  upon  the  extent  of  involvement,  and 
this  can  be  more  nearly  determined  by  the  roentgen-rays  than 


OPERABILITY 


199 


Fig.  132. — Cancer  of  cardia.     Inoperable. 


Fig.  133. — Prepyloric  cancer.     Resectable. 


200 


GASTRIC   CANCER 


by  any  other  method  (Fig.  134).  The  actual  extent  of  a  medul- 
lary cancer  corresponds  closely  to  that  indicated  radiologically. 
The  limits  of  a  scirrhous  cancer  are  much  less  sharply  defined 
in  the  roentgen  picture  and  a  generous  allowance  must  be  made 
in  estimating  the  probable  degree  of  involvement.  Even  after 
allowing  liberally  for  an  excess  of  involvement  beyond  that  indi- 
cated, the  extent  of  invasion  is  sometimes  found  to  be  far  greater 


Fig.  134. — OperaVjle  prepj'loric  cancer. 

than  suspected.  It  is  worthy  of  note  that  less  than  3^^  per 
cent,  of  gastric  cancers  go  beyond  the  pyloric  ring  into  the 
duodenum. 

Free  mobility  of  a  cancerous  stomach  is  an  item  favoring 
resectability,  while  marked  fixation  resulting  from  extension  to 
adjacent  structures  makes  successful  intervention  less  probable. 
However,  a  cancer  which  does  not  involve  the  stomach  exten- 
sively or  appear  to  have  lessened  its  mobility  materially  may 
at  operation  be  found  to  have  invaded  and  to  be  adherent  to  a 
near-lying  organ,  such  as  the  pancreas.  In  such  cases  resection 
of  the  growth  is  sometimes  impossible. 


OPERABILITY  201 

Retention  of  the  hook-form  of  the  stomach,  which  has  been 
advanced  as  an  indication  of  resectabiUty,  is  often  found  in 
cases  that  are  manifestly  inoperable. 

Regarding  metastasis,  a  factor  which  has  always  to  be  con- 
sidered, the  roentgen  examination  can  sometimes  give  informa- 
tion. Extensive  metastasis  in  the  lungs  or  an  abnormally  large 
shadow  of  the  liver  may  be  observed  during  the  screen  examina- 
tion and  these  should  always  be  looked  for.  Roentgenograms  of 
the  chest  will  give  more  definite  information  as  to  pulmonary 
metastasis^  and  as  to  the  presence  of  nodular  metastases  on  the 
upper  surface  of  the  liver  deforming  the  arch  of  the  diaphragm. 
Examination  of  the  colon  with  the  opaque  enema  will  show 
whether  the  cancer  has  invaded  the  large  bowel. 

In  past  years  many  surgeons  have  pronounced  cases  of  can- 
cer with  definite  palpable  tumors  of  the  stomach  inoperable. 
This  is  rather  extreme,  since  many  such  cancers  are  resectable, 
and  when  there  is  no  glandular  involvement  or  invasion  of  ad-< 
jacent  tissue,  the  chance  for  cure  is  good.  Further,  not  every 
palpable  tumor  is  a  cancer;  the  mass  may  be  a  perforating  ulcer 
with  adhesions,  pancreatic  cyst,  floating  spleen  or  various 
lesions  originating  in  the  gall-bladder. 

On  the  clinical  side,  the  evidences  of  inoperability  have  been 
summed  up  by  W.  J.  Mayo^  as  follows: 

'^  1.  The  cachectic  patient  with  marked  evidence  of  progress- 
ive gastric  trouble  which  has  lasted  over  a  period  of  a  number 
of  months,  with  a  fixed  tumor  lying  to  the  left.  Such  a  case 
would  be  clearly  hopeless. 

''2.  It  frequently  happens  that  with  cancer  of  any  of  the 
abdominal  viscera  there  will  be  an  escape  of  cancer  cells  into  the 
peritoneal  cavity.  These  will  drop,  by  gravity,  to  the  bottom  of 
the  pelvis  and  become  attached  often  to  the  sigmoid.  The  feel 
of  these  various  small  metastases  upon  rectal  examination  is 
very  characteristic.  In  women,  not  infrequently  transplanta- 
tion to  the  ovary  occurs,  setting  up  a  secondary  malignant  cyst. 
The  majority  of  cases  of  malignant  adenocarcinomas  of  both 


202  GASTRIC   CANCER 

ovaries  have  such  origin,  and  women  are  sometimes  unnecessarily 
submitted  to  operation  for  their  removal. 

'^3.  The  supraclavicular  fossa,  especially  the  left  side,  should 
be  examined  for  carcinomatous  glands. 

"4:.  Cancer  cells  free  in  the  abdominal  cavity  can  be  carried 
by  the  lymphatics  to  the  umbilicus,  forming  a  distinct  mass 
like  a  button.  In  doubtful  cases  I  remove,  under  local  anesthe- 
sia, a  little  portion  of  this  'button  umbilicus'  for  microscopic 
examination, 

'^5.  Metastatic  deposits,  giving  rise  to  nodular  tumors  in  the 
liver  or  peritoneal  cavity. 

^'6.  Ascitic  accumulations  in  the  abdominal  cavity,  taken  in 
connection  with  the  history  of  the  patient,  have  some  value. 
It  is  necessary  to  eliminate  other  causes  of  ascites — for  example, 
the  heart,  liver,  kidneys,  tuberculous  peritonitis,  etc." 

Roentgenologic  determination  of  the  absence  or  presence  of 
obstruction,  its  site  and  degree,  aids  materially  in  judging  the 
advisability  of  palliative  surgery  and  in  selecting  the  operation, 
whether  gastro-enterostomy,  gastrostomy,  or  jejunostomy.  In 
expressing  any  opinion  as  to  operability,  unless  the  cardia  or 
upper  media  is  definitely  implicated,  or  unless  the  growth  is  ex- 
traordinarily extensive,  the  roentgenologist  should  be  chary  of 
saying  that  a  case  is  inoperable,  as  he  may  thus  deprive  the  pa- 
tient of  relief  or  cure  at  the  hands  of  the  surgeon.  In  the  major- 
ity of  instances  exploration  alone  speaks  the  final  word  and  the 
patient  should  be  given  the  benefit  of  the  doubt.  Besides,  there 
is  always  at  least  a  remote  chance  that  the  most  confident  diagno- 
sis may  be  wrong. 

Early  Cancer. — The  term  "latent  cancer"  is  sometimes 
applied  to  cancers  which  give  rise  to  few  or  no  symptoms  or 
signs  and  which  cannot  be  diagnosed  clinically.  Since  ''latent" 
also  carries  the  sense  of  quiescence  or  dormancy,  a  condition 
which  has  not  been  proved  as  regards  gastric  cancer,  the  ad- 
jective ''early"  is  perhaps  preferable. 

Admitting  that  the  only  cure  for  cancer  is  early  operation, 


EARLY    CANCER 


203 


early  diagnosis  is  a  matter  of  prime  importance.  Admitting  also 
that  usually  there  are  no  decisive  clinical  findings  in  early  cancer, 
the  statement  is  warranted  that  next  to  the  exploring  finger  of  a 
trained  surgeon  the  roentgen-rays  will  reveal  more  cancers  in  the 
early  stages  than  will  any  other  diagnostic  means.  Hence 
every  patient  of  cancer  age  with  indefinite  gastric  symptoms 
should  be  subjected  to  a  roentgen  examination.  The  earliest 
time  at  which  cancer  may  be  found  depends  upon : 


Fig.  135. — Deformity,  a,  at  pylorus  due  to  early  cancer. 


1.  The  character  of  the  cancer,  whether  a  frank  tumor,  an 
insidious-  infiltration  or  a  cancerous  ulcer. 

2.  Its  situation. 

3.  The  examiner's  familiarity  with  the  work. 

4.  The  amount  of  roentgenologic  evidence,  together  with  the 
extent  of  clinical  corroboration. 

Cancer  w^hich  begins  candidly  as  a  tumor  projecting  into  the 
gastric  lumen  is  susceptible  of  quite  early  recognition  by  reason 
of  the  filling-defect  which  it  produces  (Fig.  135).     The  test  of 


204  GASTRIC    CANCER 

this  sign  is  its  permanence,  not  its  size,  and  we  have  been  fortu- 
nate enough  to  find  a  cancer  which  was  not  larger  than  a  cherry. 
An  infiltrative  cancer  may  invade  the  gastric  wall  without  pro- 
ducing a  recognizable  filling-defect.  In  this  event  peristalsis 
should  be  notably  absent  from  the  involved  area,  and  a  local  loss 
of  flexibility  may  be  evident  upon  palpation.  When  these  signs 
exist  alone  they  should  be  interpreted  with  caution;  but  in  con- 
junction with  a  gaping  pylorus,  achylia  and  chnical  indices,  they 
may  warrant  a  surgical  exploration. 

Carcinomatous  ulcers  for  the  most  part  show  the  same 
roentgenologic  signs  as  simple  ulcers.  However,  as  stated, 
ulcers  with  excessively  large  craters  are  open  to  the  suspicion 
of  being  cancerous. 

The  situation  of  a  small  cancer  makes  a  decided  difference  in 
the  chance  of  its  demonstration.  On  either  curvature  of  the 
pars  media  or  pars  pylorica,  filling-defects,  even  though  small, 
can  usually  be  visualized  either  on  the  screen  or  plate,  or  both; 
but  such  defects  on  the  anterior  or  posterior  wall  might  evade 
observation  even  in  the  oblique  view.  Trifling  defects  in  the 
region  of  the  gas-bubble  also  are  hard  to  find.  The  percentage 
of  cancers  in  the  pars  cardiaca,  however,  is  smaU. 

The  experience  of  the  examiner  and  his  ability  to  see  and 
interpret  slight  departures  from  the  normal  have  some  impor- 
tance in  the  diagnosis  of  early  cancers.  The  novice  would  better 
limit  his  diagnoses  to  those  cases  in  which  he  can  demonstrate  a 
permanent  filling-defect,  and  which  are  at  least  suspicious  clin- 
ically. 'Anyway,  these  features  will  be  found  in  the  vast  maj  ority 
of  patients  with  gastric  cancer  who  seek  medical  aid. 

Patients  with  early  cancer  near  the  pyloric  ring,  producing 
obstruction,  are  more  likeh^  to  come  into  the  hands  of  the  roent- 
genologist than  patients  with  early  cancer  beginning  elsewhere  in 
the  stomach.  A  six-hour  retention,  evidencing  obstruction,  may 
be  the  only  abnormality  of  which  the  observer  feels  sure.  This 
alone,  of  course,  will  not  support  a  diagnosis  of  cancer.  In 
other  cases  there  may  be  a  slight  but  permanent  irregularit}"  of 
prepyloric  contour,  with  or  without  obstructioQ,  and  it  can  be 


EARLY    CANCER  205 

said  with  certainty  only  that  a  lesion  is  present.  Correlation 
with  other  evidence  may  help  to  decide  whether  it  is  an  ulcer, 
a  cancer,  or  something  else. 

While  it  is  highl}"  important  that  gastric  cancers  be  discov- 
ered at  the  earliest  possible  moment,  it  is  also  highly  important 
that  the  patient  shall  not  be  subjected  to  needless  surgery,  and 
where  the  roentgen  findings  plus  the  clinical  features  of  the  case 
do  not  quite  justify  surgical  exploration  the  patient  should  be 
reexamined  at  short  intervals  until  a  decision  is  reached. 

The  roentgen  indications  of  gastric  cancer  vary  markedly  in 
degree  and  in  their  combinations  with  each  other,  as  will  be  seen 
in  the  case  reports  herewith  appended.  The  cases  with  which  the 
roentgenologist  has  to  deal  thus  range  all  the  way  from  those 
which  are  plainly  cancer  to  those  which  are  highly  doubtful. 
Often  he  can  be  positive  only  of  a  pathologic  condition.  In 
every  case  he  should  be  acquainted  with  the  principal  chnical 
facts,  which  should  at  least  grossly  correspond  to  his  own  find- 
ings. If  they  do  not  agree,  he  ought  to  confirm  his  own  obser- 
vations by  repeated  examinations. 

Case  90,077,  female,  aged  53.  Fourteen  months  ago  the  patient 
began  losing  weight  and  strength,  notwithstanding  a  good  appetite. 
Occasionally  she  has  had  nausea  about  an  hour  after  meals.  Six 
months  ago  a  phj^sician  made  a  gastric  analysis,  found  an  achlorhy- 
dria  and  gave  hydrochloric  acid  with  some  benefit.  For  two  months 
past  she  has  had  a  persistent  diarrhea.  Weight  loss,  41  pounds. 
Vague  sense  of  tumor-ridge  in  epigastrium.  Total  acidity  22,  all 
combined;  altered  blood.  Hemoglobin,  55.  Roentgen  findings:  Xo 
six-hour  retention.  Gross  filling-defect,  greater  curvature,  pars  media 
(Fig.  136).  Shading  off  in  lesser  curvature  of  pars  cardiaca.  Diag- 
nosis: Inoperable  carcinoma.  (In  spite  of  the  evident  inoperability 
the  patient  insisted  upon  surgical  exploration.)  Finding  at  explora- 
tion: Inoperable  carcinoma  of  body  of  stomach.  Extensive  glandular 
involvement . 

Case  102,053,  male,  aged  56.  Many  j'ears  ago  the  patient  had 
several  attacks  of  sudden,  severe,  epigastric  pain,  often  requiring 
morphin,  but  has  had  none  of  these  attacks  during  the  past  ten  years. 
His  present  trouble  began  eight  months  ago  and  consists  of  an  indefi- 
nite distress  and  soreness  in  the  epigastrium,  coming  three  or  four 


206 


GASTRIC   CANCER 


Fig.  136. — Case  90,077.     Roentgenogram  showing  appearance  of  medullary  type  of 

cancer  at  a. 


Fig.   137. — Case  102,053.     Cancer  defect  at  a. 


REPORT    OF    CASES  207 

hours  after  meals  and  relieved  by  food.  Appetite  good.  Net  weight 
loss  20  pounds,  but  none  during  past  four  months.  Total  acidity  10; 
all  combined.  Roentgen  findings:  No  retention  from  six-hour  meal. 
Filling-defect,  pyloric  portion  (Fig.  137).  Diagnosis:  Cancer.  Con- 
sidered operable  in  so  far  as  extent  of  gastric  involvement  was  con- 
cerned. Findings  at  operation:  Carcinoma  pyloric  end  of  stomach. 
Resection  half  of  stomach.     Pathologist's  report:  Carcinoma. 

Case  109,744,  female,  aged  38.  Eleven  months  ago  she  began 
having  slight  attacks  of  pyrosis  and  epigastric  distress.  Later  the 
epigastric  distress  became  rather  spasmodic  but  was  not  severe,  had  no 
food  relation,  and  the  attacks  were  very  brief  in  duration.  Generally 
considered,  pain  has  not  been  a  marked  feature.  She  has  vomited 
but  twice.  Nine  months  ago  she  first  noticed  a  small,  very  movable 
tumor  in  the  epigastrium  a  little  to  the  left  of  the  midline.  This  has 
since  increased  slightly  in  size.  Poor  appetite.  Weight  loss,  20 
pounds.  Palpable,  movable  tumor,  the  size  of  a  fist,  very  like  a 
wandering  spleen.  Hemoglobin,  68.  Roentgen  findings:  Retention 
of  one-fourth  the  six-hour  meal.  Definite  prepyloric  filling-defect 
(Fig.  138).  Findings  at  operation:  Carcinoma,  pyloric  end  of  stom- 
ach, adherent  to  pancreas  and  transverse  mesocolon.  Resection 
three-fifths  of  stomach.     Pathologist's  report:  Carcinoma. 

Case  97;408,  male,  aged  43.  Five  years  ago  the  patient  had  occa- 
sional attacks  of  vomiting,  sometimes  of  food  taken  the  previous  day. 
These  ceased  after  medical  treatment  and  the  patient  was  well  until 
five  weeks  ago.  At  this  time  he  began  to  have  attacks  of  epigastric 
pain,  aggravated  by  exercise  and  relieved  by  rest.  No  food  relief. 
Occasionally  takes  hot  water  or  soda  at  night  to  relieve  the  pain.  No 
loss  of  weight.  Total  acidity  86;  free  62;  combined  24;  no  food  rem- 
nants. Roentgen  findings:  Retention  of  half  the  six-hour  meal. 
Small  prepyloric  filling-defect  (Fig.  135).  Active  peristalsis.  Diag- 
nosis: Lesion  at  the  pylorus.  (As  the  pathologist's  report  shows,  this 
proved  to  be  an  ulcer  with  early  carcinoma.  Many  similar  cases 
diagnosed  roentgenologically  as  cancer  prove  to  be  ulcer  and  vice 
versa.  Therefore,  in  the  absence  of  pathognomonic  signs,  the  roent- 
genologist wdll  spare  himself  embarrassment  by  simply  reporting  the 
presence  of  a  lesion,  and  leave  the  final  diagnosis  to  the  microscopist.) 
Findings  at  operation:  Early  carcinoma  on  ulcer,  pyloric  end  of 
stomach.  Resection  4  inches  of  stomach;  duodenum  reattached  to 
pyloric  end,  direct  union.  Pathologist's  report:  Ulcer;  early 
carcinoma. 

Case  142,921,  female,  aged  32.  Five-year  history  of  severe  epi- 
gastric pain  daily  for  a  period  of  about  three  months  each  year,  begin- 


208 


GASTRIC    CANCER 


Fig.  138.- — Case  109,744.     Cancer  deformity  at  a. 


YiG.   139. — Case  142,921.      Deep,  uarrow  incisura,  body  of  stomach. 


REPORT    OF    CASES 


209 


Fig.   140. — Case  96,106.     Six-hour  residue. 


Fig.   141. — Case   96,106.    Stomach  after  filling.     The  prepyloric  deformity  is  evident. 
14 


210  GASTRIC    CANCER 

ning  in  June  or  July.  At  first  tlie  pain  came  within  a  few  minutes 
after  meals.  Now  comes  about  one  hour  after  eating,  is  of  variable 
duration  and  is  eased  by  posture,  food  and  medicines.  In  attacks 
may  vomit  three  or  four  times  daily.  Copious  hematemesis  two  years 
ago.  Some  weight  loss.  Roentgen  findings:  No  six-hour  retention. 
Incisura,  pars  media.  No  niche  or  filling  defect  on  lesser  curvature. 
The  possibility  of  an  ulcer  was  thought  of  and  the  patient  was  rerayed 
after  being  given  belladonna.  At  the  second  examination  the  incisura 
was  still  present.  Diagnosis:  Gastric  ulcer.  (It  is  interesting  to 
note  that  the  persistent  incisura  was  the  only  roentgen  sign  observable, 
either  on  the  screen  or  plate  (Fig.  139).  Findings  at  operation:  Ulcer 
lesser  curvature,  size  of  a  fifty-cent  piece,  producing  hour-glass  deform- 
ity. Excision;  posterior  gastro-enterostomy.  Pathologist's  report: 
Section  of  ulcer  shows  colloid  carcinoma. 


Fig.  142. — Case  96,106.     Resected  pyloric  end  of  stomach.     Ulcerating  carcinoma. 

Case  96,106,  woman,  aged  41.  Cholecystectomy  seven  years  ago 
for  cystic  gall-bladder  with  stones.  Three  years  later  operation  for 
acute  strangulated  left  inguinal  hernia.  Since  the  latter  operation, 
she  has  had  occasional  sharp  sticking  pain  in  the  left  hypochondrium. 
For  a  month  past  she  has  had  dull  epigastric  pain  immediately  after 
meals  with  relief  by  bowel-movement.  During  the  past  two  weeks  the 
pain  has  been  constant.  Appetite  good,  but  she  is  afraid  to  eat. 
Weight  loss,  20  pounds.     On  palpation  a  hard  mass  can  be  felt  in  the 


RESECTABLE    CANCERS 


211 


Fig.  145. 


Fig.   146. 


Fig.  147.  Fig.  148. 

Figs.  143,  144,  145,  146,  147,  148.— Cancers  of  thejstomach;  resectable. 


212 


GASTRIC   CANCER 


Fig:  151. 


Fig.  152. 


Fig.  153.  Fig.  154. 

Figs.  149,  150,  151,  152,  153,  154. — Cancers  of  the  stomach;  inoperable. 


REFERENCES  213 

epigastrium,  which  moves  with  inspiration.  Gastric  analysis:  Total 
acidity  14,.  all  combined;  food  remnants,  mucus,  blood.  Roentgen 
findings:  Retention  of  half  the  motor  meal  after  six  hours  (Fig.  140). 
Concentric  prepyloric  filling-defect  corresponding  to  a  palpable  mass 
(Fig.  141).  Diagnosis:  Cancer;  operable  so  far  as  extent  of  gastric 
involvement  is  concerned.  Findings  at  operation:  Cancer,  pyloric 
region,  involving  both  curvatures.  Edema  in  gastro-colic  omentum. 
Resection  of  two-thirds  of  stomach.  Anterior  gastro-enterostomy. 
Resection  of  portion  of  mesentery  of  transverse  colon.  Pathologist's 
report:  Cancer  (Fig.  142). 

REFERENCES 

1.  Mayo,    W.    J.:  ''The    Cancer    Problem."     Journal-Lancet,    1915, 

XXXV,  339-343. 

2.  Gkaham,  C:  ''Differential  Diagnosis  of  Diseases  Causing  Gastric 

Disturbance,"     Northwestern  Lancet,  1910,  n.s.,  xxx,  139-142. 

3.  Moore,  A.  B.  and  Carman,  R.  D.:     "Radiographic  Diagnosis  of 

Metastatic  Pulmonary  Malignancy."     Am.  Jour.  Roent.,  1916, 
iii,  126-131. 

4.  Mayo,    W.    J.:  "Cancer    of    the   Stomach;   Its   Surgical   Cure." 

Surg.,  Gynec.  and  Obstet.,  1912,  xiv,  115-119. 


CHAPTER  X 
FIBROMATOSIS  OF  THE  STOMACH 

Leather-Bottle    Stomach — Cirrhosis — Fibrosis — Linitis    Plastica 

The  ''leather-bottle  stomach"  to  which  Brinton^  gave  the 
name  ''linitis  plastica"  has  occasioned  considerable  difference 
of  opinion  as  to  its  malignancy.  Brinton  regarded  the  condition 
as  benign,  his  view  having  eminent  indorsement,  but  many  path- 
ologists are  either  skeptical  of  its  benignancy  or  firmly  of  the 
opinion  that  it  is  malignant.  Thompson^  says:  "The  con- 
troversy owes  its  origin  to  the  fact  that  there  occurs  in  the  stom- 
ach a  diffuse  infiltrating  form  of  scirrhous  cancer  which  in  its 
distribution  resembles  fibromatosis,  while  at  the  same  time  it  dif- 
fers so  much  in  its  naked-eye  and  microscopic  appearances  from 
the  classical  forms  of  gastric  carcinoma  that  its  true  character  is 
not  capable  of  being  established  without  a  thorough  histologic 
examination."  Such  stomachs,  from  their  gross  appearance, 
are  often  described  by  the  surgeon  as  being  of  the  leather- 
bottle  variety,  although  painstaking  microscopic  examination 
will  reveal  the  presence  of  cancer-cells.  The  confusion  is  shown 
also  by  the  large  number  of  synonyms,  one  of  which  is  "diffuse 
carcinoma,"  and  is  increased  by  the  fact  that  fibromatosis  may 
occur  in  association  with  cancer,  which  latter,  as  viewed  by  the 
partisans  of  the  benignancy  of  the  leather-bottle  stomach,  is  re- 
garded as  a  superaddition.  Further,  the  question  has  perhaps 
been  somewhat  involved  with  syphiUs  and  tuberculosis  of  the 
stomach. 

Fibrosis  may  be  either  localized  or  diffuse  and  general. 
When  localized  it  is  said  to  have  a  predilection  for  the  pyloric 
portion.  Ulceration  of  the  mucosa,  either  circumscribed  and 
punched-out,  or  widespread  and  shallow,  is  reported  in  the 
majority  of  the  cases.  In  the  diffuse  form,  the  stomach  is  dim- 
inished in  size,  and  is  converted  into  a  stiffened  tube  which 
does  not  collapse  when  opened.     On  microscopic  section,  the 

214 


LEATHER-BOTTLE    STOMACH  215 

submucosa  is  found  converted  into  firm,  tough,  white,  fibrous 
tissue,  up  to  a  centimeter  or  more  in  thickness.  The  muscularis 
is  hypertrophied  and  shot  through  with  fibrous  septa.  A  num- 
ber of  cases  reported  showed  no  cancer  cells.  Whether  a  more 
prolonged  and  careful  search  might  possibly  have  revealed  such 
cells  is  a  matter  of  doubt. 

From  a  clinical  standpoint  McGlannan^  gives  the  following 
summary:  ''The  disease  is  one  of  adult  life.  Lyle's*  statistics 
show  that  the  greatest  number  of  cases  occur  between  the  ages 
of  40  and  60  years,  and  about  twice  as  often  in  men  as  in  women. 
Some  form  of  disease  associated  with  general  circulatory  stasis  is 
frequently  noted  in  the  previous  history  of  the  patient.  The 
symptoms  of  onset  are  generally  slight  indefinite  dyspepsia 
(Lyle),  loss  of  appetite,  epigastric  distress  on  taking  food,  and 
eructations.  The  symptoms  gradually  become  marked  and 
progressive,  reaching  those  of  definite  stenosis,  and,  if  unrelieved, 
end  in  anemia,  starvation,  cachexia  and  death.  Occasionally 
the  onset  is  quite  abrupt,  and  the  obstructive  symptoms  come  on 
rapidly.  Gastric  examination  shows  a  diminished  capacity  of 
the  stomach,  and  the  stomach  cannot  be  distended.  The  thick 
stomach  has  been  palpated  as  a  sausage-shaped  tumor  in  the 
epigastrium.  Chemical  examination  of  the  contents  usually 
shows  diminished  acidity  with  little  or  no  free  hydrochloric  acid. 
Lactic  acid  may  be  present.  Blood  either  in  stomach  contents 
or  feces  is  unusual.  Roentgen  examination  offers  the  best 
means  of  recognizing  the  lesion." 

The  roentgenologic  manifestations  of  the  condition  are  prac- 
tically identical  with  those  of  cancer,  more  particularly  those  of 
scirrhous  cancer.  The  filling-defect  produced  by  the  thickened 
wall  is  likely  to  have  a  relatively  smooth  inner  margin,  and  a  cor- 
responding mass  may  be  felt.  Peristalsis  is  absent  from  the  in- 
volved area.  The  pylorus  is  either  gaping  or  obstructed.  When 
the  involvement  is  extensive  there  is  a  striking  lack  of  expansi- 
bility and  flexibility,  and  the  stomach  is  small,  contracted  and 
drawn  upward.  When  the  process  begins  at  the  pylorus  and 
produces  obstruction  early,  dilatation  of  the  stomach  results. 


216 


FIBROMATOSIS   OF   THE    STOMACH 


Fig.   155.— Case  146.919. 


Fig.  156.— Case  102,013. 


REPORT   OF    CASES  217 

Case  146,919,  male,  aged  52.  For  two  years  he  has  had  brief 
attacks  of  nausea  occurring  about  once  a  week  and  mostly  when 
stomach  was  empty.  A  year  ago  he  had  some  tenderness  and  epi- 
gastric pain,  an  hour  after  meals,  relieved  by  vomiting.  These 
attacks  ceased  and  he  felt  well  until  three  months  ago,  when  food 
seemed  to  lag  at  the  cardia  but  passed  into  the  stomach  after  belching. 
He  vomits  if  he  eats  rich  or  large  amounts  of  food.  Weight  loss,  16 
pounds  in  three  months.  Mass  in  the  epigastrium  moving  with 
respiration.  Total  acidity  6,  all  combined.  Roentgen  findings:  No 
retention  from  the  six-hour  meal.  Gaping  pylorus.  Prepyloric  filling 
defect;  lumen  smoothly  narrowed  (Fig.  155).  Palpable  mass  corre- 
sponding to  defect.  Diagnosis:  Cancer.  Findings  at  operation: 
Tumor  beginning  at  pylorus,  extending  onto  lesser  curvature  about  3 
inches.  Pylorus  freely  movable.  Growth  not  causing  marked 
obstruction.  Leather-bottle  type  of  stomach.  Resection.  Patholo- 
gist's report:  Ulcer.  Greatly  thickened  submucosa  and  musculature 
with  marked  round-cell  infiltration  and  fibrosis.  Unable  to  make 
definite  diagnosis  of  carcinoma. 

Case  102,013,  female,  aged  69.  Two  years  ago  she  noticed  the 
sensation  of  a  lump  in  her  stomach  soon  after  meals.  A  year  later 
she  could  feel  a  mass  in  the  epigastrium  which  has  since  steadily 
increased  in  size.  Eight  months  ago  she  began  vomiting  immediately 
after  meals,  without  pain  or  nausea,  but  because  of  fullness  even  when 
taking  ordinary  amounts.  Appetite  good.  Weight  loss,  45  pounds. 
Oblong  mass  palpable  in  epigastrium.  Total  acidity  6,  all  combined; 
no  food  remnants.  Hemoglobin  85.  Roentgen  findings :  No  retention. 
Gaping  pylorus.  Stomach  small  and  irregularly  contracted.  Walls 
not  fiexible  to  palpation.  No  peristalsis  seen.  Diagnosis:  Cancer 
(Fig.  156).  Findings  at  exploration:  Inoperable  tumor  involving 
entire  stomach.  Leather-bottle  stomach.  Some  glandular  thicken- 
ing but  no  metastasis.     No  microscopic  diagnosis. 

Case  124,629,  male,  aged  44.  Eight  months  previously  the  patient 
began  to  have  epigastric  pain,  coming  immediately  after  the  meal  and 
lasting  to  one  hour.  The  attacks  continued  until  six  weeks  ago  since 
when  he  has  felt  quite  well.  Weight  loss,  15  pounds.  Fairly  firm 
tumor  to  left  of  umbilicus,  visibly  modified  in  shape  by  peristaltic 
wave  (?).  Total  acidity  66;  free  60;  combined  6;  mucus.  Roentgen 
findings:  No  retention.  Gross  filling  defects  lower  two-thirds  of 
stomach,  changing  in  aspect  with  palpation  and  shifting  of  patient. 
Without  any  correlation  with  the  clinical  history,  the  condition  was 
believed  to  be  an  extra-gastric  tumor  (Fig.  157).  Findings  at  opera- 
tion: Huge   leather-bottle   stomach,    fiattened    out,  involving   ail  of 


218 


FIBROMATOSIS    OF   THE    STOMACH 


stomach  except  the  cardiac  end.  Tumor  forming  a  mass  shaped 
exactly  hke  a  large  water-bottle.  Carcinoma.  Resection  of  three- 
fourths  of  stomach.  Pathologist's  report :  Carcinoma  with  no  glandu- 
lar involvement. 


Fig.   157.— Case  124,629. 

REFERENCES 

1.  Beinton,  W. :  ''The  Diseases  of  the  Stomach,  with  an  Introduc- 

tion on  its  Anatomy  and  Physiology."     London,  J.  Churchill, 
1859,  xii,  406. 

2.  Thompson,  A.  and  Graham,  J.  M.:  "Fibromatosis  of  the  Stomach 

and  its  Relation  to  Cancer  and  Ulcer."     Annals  of  Surgery, 
1913,  Iviii,  10-26. 

3.  McGlannan,  a.:  "Linitis  Plastica  Hypertrophica  (Leather-bottle 

Stomach),  Report  of  a  Case."     Jour.  A.  M.  A.,  1916,  Ixvi, 
92-94. 

4.  Lyle,  H.  H.  M.:  "Linitis  Plastica."     Annals  of  Surgery,    1911, 

liv,  625-668  (with  extensive  bibliography). 


CHAPTER  XI 
SYPHILIS  OF  THE  STOMACH 

The  difficulty  of  substantiating  a  diagnosis  of  gastric  syphilis 
has  given  rise  to  much  skepticism  as  to  the  frequency  of  its  oc- 
currence. For  proof,  reliance  must  be  had  upon  the  history,  the 
coexistence  of  syphilitic  lesions  elsewhere,  the  Wassermann 
reaction,  the  improvement  after  antiluetic  treatment,  and  the 
microscopic  examination  of  tissue  exsected  from  the  stomach. 

It  is  perfectly  obvious  that  even  the  most  complete  and  de- 
tailed history  of  a  supposedly  luetic  infection  may  be  fallacious. 
The  concurrence  of  manifestly  syphilitic  lesions  elsewhere  does 
not  prove  beyond  cavil  that  an  associated  gastric  disorder  is  also 
syphilitic.  The  Wassermann  test,  though  so  reliable  that  it  has 
become  a  diagnostic  mainstay,  is  not  infallible.  Accepting  a 
positive  Wassermann  reaction  as  proof  of  a  syphilitic  infection, 
it  does  not  necessarily  follow  that  a  gastric  lesion  in  the  same  per- 
son is  also  luetic.  Improvement  or  apparent  cure  after  specific 
treatment  has  varying  weight  depending  upon  the  thoroughness 
of  the  clinical,  physical  and  roentgenologic  examinations. 
Microscopic  study  of  tissue  from  the  stomach,  unless  spirochetes 
can  be  demonstrated,  is  chiefly  of  value  by  showing  the  absence 
of  malignancy,  although  the  finding  of  periarteritis  and  end- 
arteritis has  some  indicative  value. 

However,  the  presumption  that  syphilis  may  affect  any  organ 
in  the  body  and  the  increasing  number  of  case-reports  of  lues 
gastrica  strongly  support  not  only  the  fact  of  its  existence  but  a 
frequency  of  occurrence  greater  than  is  generally  admitted. 

The  evidence  upon  which  the  diagnosis  was  based  in  these 
cases  has  diverse  degrees  of  impressiveness,  and  none  of  it  will 
wholly  withstand  rigid  criticism,  but  it  is  indicative  of  three 
varieties  of  gastric  syphilis,  namely: 

219 


220  SYPHILIS    OF   THE    STOMACH 

1.  Simple  syphilitic  gastritis. 

2.  Syphilitic  ulcer. 

3.  Syphilitic  gummata,  hyperplasia,  sclerosis  or  tumor- 
forraation. 

According  to  Cronin/  the  first  case  of  syphilitic  gastritis  was 
reported  in  1839  by  Andral,^  who  had  two  cases  of  chronic  gas- 
tritis cured  by  mercury.  Rudniew  is  quoted  by  Myer^  as  saying 
that  most  syphilitics  have  gastric  syphilis,  and  that  in  the  erup- 
tive stage  they  have  an  eruption  in  the  stomach  like  that  on  the 
skin.  It  is  quite  possible  that  the  "gastric  crises"  of  tabetics 
may  sometimes  be  mistaken  for  an  actual  gastritis,  and  with  the 
scant  number  of  case-reports  and  scanter  proof  the  question  of 
its  existence  or  frequency  must  be  left  suh  judice.  The  roent- 
genologist is  not  directly  interested  in  the  condition,  for  at  most 
the  roentgenologic  appearances  could  only  be  of  negative  worth 
by  failing  to  demonstrate  organic  change. 

The  occurrence  of  syphilitic  gastric  ulcer  is  well  sustained  by 
cases  reported.  Tuohy^  suggests  that  the  diagnosis  "gastric 
ulcer"  is  anatomic,  not  pathologic,  and  that  perhaps  many  of 
these  ulcers  are  of  syphilitic  origin.  Neumann^  holds  that  20 
per  cent,  of  the  round  ulcers  occur  in  syphilitic  persons.  Fen- 
wick^  remarks  that  luetic  ulcers  are  characterized  chnically  by 
severity  of  pain  and  vomiting,  infrequency  of  hematemesis,  re- 
sistance to  ordinary  treatment,  and  tendency  to  recurrence. 
Pathologically,  it  is  noteworthy  that  in  many  of  the  cases  pub- 
lished the  ulcers  were  multiple. 

Tuohy'^  reports  three  cases,  one  of  which  was  operated  on  at 
the  Mayo  Clinic  and  is  described  herewith  in  detail.  All  by  the 
roentgen-ray  showed  hour-glass  contraction  of  the  stomach,  all 
had  positive  Wassermanns,  and  all  improved  decisivel}^  after 
antiluetic  treatment. 

Brugsch  and  Schneider^  give  a  clinical  analysis  of  106  tertiary 
luetic  patients  who  had  gastric  symptoms.  In  3  the  presence  of 
a  tumor  was  suspected,  but  it  was  questionable  whether  or  not 
the  mass  was  of  a  gummatous  nature.  Hypersecretion  was 
noted  in  16,  achylia  in  24,  abortive  gastric  crises  in  33,  and  motor 


SYPHILITIC    ULCER  221 

irritability  in  18.  The  motor  disturbance  was  demonstrated  by 
the  roentgen-ray  in  several  cases  and  consisted  of  hyperperistalsis 
and  spastic  contractions.  In  13  gastric  ulcer  was  present  or 
strongly  suspected.  These  authors  call  attention  to  the  fre- 
quency of  achylia  in  lues  and  its  common  association  with 
luetic  gastric  ulcer. 

McNeiP  reports  an  annular  syphilitic  ulcer  almost  completely 
encircling  the  pylorus,  with  marked  thickening  of  the  region. 
Microscopically  there  was  a  marked  periarteritis.  No  spiroche- 
tes could  be  demonstrated  in  the  sections.  xAiter  resection  and 
antisyphilitic  treatment  the  patient  made  a  good  recovery. 

Downes  and  Le  Wald^  have  had  8  cases  of  syphilis  of  the 
stomach  in  which  the  diagnosis  was  estabhshed  with  a  fair  degree 
of  certainty.  The  ages  of  the  patients  ranged  from  14  to  63. 
Two  of  the  cases  were  congenital,  the  others  acquired.  Histo- 
logically, the  authors  state  that  gastric  syphilis  is  characterized 
by  gummata,  single  or  multiple,  which  start  in  the  submucosa 
and  go  on  to  infiltration,  ulceration  and  cicatrization  in  varying 
degrees.  Clinically,  they  note  that  the  symptoms  when  consid- 
ered in  a  general  way  differ  very  little  from  those  of  other 
lesions  of  the  stomach  of  equal  extent  and  hke  location.  How- 
ever, the  pain  of  a  luetic  ulcer  lacks  the  periodicity  of  simple 
ulcer,  is  less  influenced  by  food,  is  often  described  as  of  a  gnaw- 
ing character  and  is  persistent.  Vomiting  was  a  marked  symp- 
tom in  their  cases  almost  from  the  beginning.  In  3  cases  the 
acids  were  low  and  all  combined.  In  2  the  total  acidity  was 
higher  but  with  a  large  proportion  of  combined  acid.  Roent- 
genologically,  their  findings  included  deformity  and  diminution 
in  size  of  the  stomach,  compensatory  dilatation  of  the  esophagus, 
dumb-bell  (hour-glass)  stomach,  and  gaping  or  obstruction  of 
the  pylorus. 

The  third  type  of  gastric  lues,  the  infiltrative,  cirrhotic  or 
tumor-producing  type,  is  of  especial  interest  from  the  roent- 
genologic standpoint,  since  by  the  roentgen-ray  a  gumma  or  a 
thickening  of  the  gastric  wall  can  be  demonstrated  with  greater 
certainty  than  an  ulcer.     While  it  is  claimed  that  gummata  in 


222  SYPHILIS    OF   THE    STOMACH 

the  stomach  rarely  attain  large  size  and  soon  ulcerate,  there  is 
reasonable  evidence  of  at  least  a  few  notable  exceptions  in  which 
the  gummatous  hyperplasia  was  extensive.  Thus  Cronin^  has 
collected  the  cases  of  Cornil,^°  Birch-Hirschfeld,^^  Einhorn/- 
Faroy^^and  others,  in  which  gummatous  infiltrations  were  found, 
ranging  in  breadth  from  2  cm.  to  8  inches,  and  having  various 
situations  in  the  stomach.  J.  S.  Myer^  records  2  cases.  One 
patient,  aged  21,  had  a  visible  and  palpable  epigastric  tumor  the 
size  of  half  an  orange,  with  gastric  symptoms,  stagnation  of  the 
Ewald  breakfast,  many  clinical  evidences  of  syphilis  and  a  posi- 
tive Wassermann.  Disappearance  of  the  tumor  and  clinical 
cure  resulted  from  specific  treatment.  The  other,  a  man  aged 
32,  at  exploration  was  found  to  have  a  mass  as  large  as  a  hen's 
egg  on  the  lesser  curvature,  adherent  everywhere  and  obstructing 
the  pylorus.  After  gastro-enterostomy  and  antiluetic  treat- 
ment the  tumefaction  disappeared. 

Similar  cases,  in  which  roentgenologic  observations  were  also 
made,  are  those  of  Meyers, ^^  Holitsch,^^  Christie,"  Muhlmann,^'^ 
Mills ^®  and  Morgan.  ^^ 

Meyers'^  case  was  a  male,  aged  22,  with  a  history  of  syphilitic 
infection  five  3''ears  previously  and  positive  Wassermann.  The 
gastric  symptoms,  consisting  chiefly  of  distress  after  meals, 
covered  a  period  of  seven  months,  and  there  was  marked  weight 
loss.  A  palpable  mass  developed  in  the  epigastrium,  and  the 
roentgenogram  showed  biloculation  of  the  stomach.  Treat- 
ment resulted  in  rapid  recovery. 

The  case  reported  by  Holitsch"  was  that  of  a  woman,  33 
years  of  age,  with  a  luetic  history  and  positive  Wassermann. 
For  six  months  she  had  pain  directly  post-coenam,  tenderness  in 
the  epigastrium,  and  loss  of  weight,  but  no  cachexia.  No  free 
HCl  was  found  in  the  test  meal.  The  roentgenogram  depicted 
a  marked  hour-glass  contraction.  This  was  confirmed  at  opera- 
tion (jejunostomy)  and  the  stomach  was  found  to  be  shrunken 
and  thick-walled.  Microscopic  examination  of  sections  from 
the  stomach  was  negative  for  tuberculosis  or  carcinoma.     The 


SYPHILITIC    TUMOR  223 

patient  improved  under  specific  treatment,  and  subsequent 
roentgenograms  showed  widening  of  the  stenotic  area. 

Christie  ^"^  describes  a  case  of  syphiUtic  tumor  of  the  stomach 
which  diminished  after  treatment  with  salvarsan,  then  recurred, 
as  indicated  by  the  roentgen  examination. 

Muhlmann's^^  case  was  that  of  a  woman,  aged  27,  who  gave 
a  history  of  lues,  and  dyspeptic  symptoms,  indicative  of  a  con- 
tracted stomach  with  weight  loss,  positive  Wassermann,  absence 
of  free  HCl,  and  the  suggestion  of  a  palpable,  flat,  epigastric 
tumor.  The  roentgen-ray  show^ed  a  small  stomach  without 
peristalsis,  reflux  into  the  esophagus,  a  gaping  pylorus,  and  local 
contractions.  At  operation  the  stomach  was  found  to  be  small, 
shrunken  and  thick-walled.  A  portion  of  the  wall  excised  for 
microscopic  examination  showed  loss  of  mucosal  epithehum 
and  thickening  of  the  submucosa.  Antiluetic  treatment  after 
gastro-enterostomy  was  followed  by  considerable  improvement. 

The  roentgenogram  of  Mills'  ^^  case  showed  massive  filling- 
defects  in  the  pyloric  portion  of  the  stomach,  almosf  obhterating 
this  region.  After  gastrojejunostomy  and  specific  treatment 
the  gastric  shadow  was  restored. 

Morgan^^  reports  8  cases  of  suspected  gastric  syphilis.  In  6 
of  these  the  roentgen  examination  showed  deformity  and  fill- 
ing-defects in  the  stomach  at  the  pyloric  end,  which  in  3  cases  dis- 
appeared or  were  greatly  diminished  after  antiluetic  treatment. 

Brunner^"  abstracts  from  the  literature  13  cases  of  gastric 
syphilis  in  which  surgical  operations  were  performed,  including 
resection,  gastro-enterostomy  and  pyloroplasty.  He  discusses 
gastric  lues  from  various  standpoints. 

The  symptoms  of  gastric  syphilis  are  not  sufficiently  charac- 
teristic, without  laboratory  aids,  to  differentiate  it  from  other 
organic  or  even  functional  disorders  of  the  stomach.  The  in- 
frequency  of  hematemesis  in  luetic  ulcer  as  compared  with 
simple  ulcer,  which  has  been  stressed  by  some  observers,  has 
numerous  disconcerting  exceptions.  Achylia  has  been  observed 
in  a  large  percentage  of  the  cases  and  was  a  constant  finding  in 
our  own,  but  this  also  has  its  exceptions.     Besides,  an  achyUa  is 


224  SYPHILIS   OF   THE    STOMACH 

more  likely  to  suggest  cancer  rather  than  syphilis.  Neither  are 
the  roentgenologic  manifestations  of  gastric  lues  distinctive  and 
pathognomonic,  although  in  both  the  ulcerative  and  hyper- 
plastic forms  the  roentgen-ray  signs  of  gastric  pathology  are 
well-marked.  The  cases  of  luetic  ulcer  reported  by  others, 
together  with  our  own,  showed  organic  hour-glass  contraction 
as  their  principal  sign.  The  absence  of  a  niche,  accessory 
pocket  or  typical  incisura — classic  signs  of  ordinary  gastric 
ulcer — is  worthy  of  remark,  but  is  not  conclusive  that  they  never 
occur  in  syphilitic  ulcer.  When  the  process  goes  on  to  extensive 
infiltration,  sclerosis  or  hyperplasia,  the  roentgen  evidence  of  a 
lesion  becomes  still  more  pronounced.  Deformity  of  the  gastric 
contour  is  obvious,  and  this  may  be  associated,  in  various  com- 
binations, with  diminution  in  size  of  the  stomach,  reflux  into  and 
compensatory  dilatation  of  the  esophagus  in  varying  degrees, 
lessened  flexibility  and  mobility  of  the  gastric  walls,  absence  of 
peristalsis,  and  gaping  or  obstruction  of  the  pylorus.  Review- 
ing the  histories  of  our  own  cases  in  which  gastric  syphilis  was 
thought  to  exist,  two  features  are  noteworthy:  first,  the  absence 
of  a  palpable  mass  corresponding  to  the  filling-defect,  the  ma- 
jority of  which  were  quite  gross;  second, "the  low  percentage  of 
retentions  from  the  six-hour  meal  as  compared  with  cancer 
retentions. 

Usually  the  examiner's  first  thought  is  of  cancer,  and  if  he 
considers  the  roentgenologic  picture  only  he  will  probably  make 
this  diagnosis.  But,  if  he  is  conservative,  he  may  be  impressed 
by  the  discrepancy  betweea  the  extent  of  the  lesion  and  the 
general  condition  of  the  patient,  who  is  often  under  the  can- 
cer-age, is  anemic  rather  than  cachectic,  and  is  not  markedly  weak- 
ened  or  emaciated.  With  these  signs  present  in  a  patient 
whose  history  suggests  the  possibility  of  lues,  the  clinical  and 
roentgenologic  examination  should  be  supplemented  by  labora- 
tory or  therapeutic  tests  for  syphilis.  Final  diagnosis  will 
require  substantiation  from  every  source. 

The  histories  of  a  few  cases  follow: 


REPORT    OF    CASES  225 

Case  92,014,  male,  aged  33.  Neisser  at  24.  Typhoid  at  25. 
Primary  lesion  with  light  secondaries  at  26.  History  of  continuous 
stomach  trouble  for  three  years.  Sense  of  fullness  and  heaviness  in 
epigastrium.  Food  when  swallowed  apparently  is  obstructed  at 
entrance  to  stomach,  and  occasions  so  much  discomfort  that  he  vomits, 
or  induces  vomiting.  For  two  years  has  been  on  strictly  liquid  diet. 
Weight  loss,  20  pounds.  Total  acidity  25,  all  combined;  food 
remnants.  Wassermann,  total  inhibition.  Roentgen  findings:  First 
examination,    September    13,    1913.     Retention    of    one-fourth    the 


Fig.   158.— Case  92,014. 

six-hour  meal.  High  hour-glass  stomach.  Second  examination;  Sep- 
tember 15,  1913  (after  belladonna) :  Organic  hour-glass  stomach.  No 
palpable  mass.  Diagnosis:  Probable  gastric  syphilis  (Fig.  158). 
Antiluetic  treatment  was  begun  and  the  patient  was  reexamined 
November  18,  1913,  and  February  10,  1914.  At  both  these  examina- 
tions the  appearance  of  the  stomach  was  found  to  be  unchanged,  and 
there  was  still  a  small  retention  from  the  six-hour  meal.  The  patient 
went  to  operation  April  25,  1914.  Findings  at  operation:  Hour-glass 
stomach.  Multiple  ulcers  and  strictures  involving  pyloric  end  and 
extending  well  up  into  body  of  stomach.  The  centers  of  ulceration 
involve  two  distinct  areas,  one  shortly  above  the  pylorus,  the  other  in 
the  body  of  the  stomach.     The  whole  stomach  is  converted  into  a 


226  SYPHILIS    OF   THE   STOMACH 

thick  massive  formation  of  scar-tissue,  contracted  and  typically 
syphilitic  in  appearance.  The  obstruction  is  extreme.  The  disease 
stopped  short  at  the  duodenum.  The  liver  contained  a  number  of 
small  areas,  something  like  cirrhosis,  but  not  distinct  nodules,  evi- 
dently syphilitic.  Resection:  End  of  duodenum  implanted  into 
stomach.  Pathologist's  report:  Gastric  ulcer.  The  gross  specimen 
is  shown  in  Fig.  159. 

Macroscopically  the  resected  pyloric  portion  of  the  stomach  pre- 
sents a  smooth  uniform  mucosa  with  three  small  superficial  ero- 
sions. Gross  section  shows  marked  thickening  of  submucosa  and 
musculature. 


Fig.  159. — Gross  specimen  from  Case  92,014. 


Microscopic  sections:  (Figs.  160  and  161)  Mucosa  atrophic. 
Submucosa  greatly  increased  in  thickness,  from  connective-tissue 
hyperplasia.  Many  blood-vessels  of  various  sizes,  with  walls  hyper- 
trophied  and  intima  destroyed,  and  considerable  round-cell  infiltra- 
tion about  them.  Musculature  twice  its  normal  thickness,  with 
separation  of  its  bundles  by  old  connective  tissue  rich  in  blood- 
vessels and  round  cells.     No  evidence  of  malignancy  found. 

Subsequent  history:  Eight  months  after  operation  the  patient 
writes  that  his  general  condition  is  improved,  but  that  he  is  unable  to 


REPORT    OF    CASES 


227 


Fig.    160. — Case  92,014.     Section  of  tissue  from   stomach,   4x.      a,  atrophic  mucosa, 
curling  due  to  fixing  solution;  b,  hypertrophied  submucosa;  c,  thickened  musculature. 


yr    J  4^f      f^r    f^^  ?     "*    ^     "1 

-.  ..  r-     ■♦t?t^    ,  ,i  /'.     -^i     .K*J'  ~      "       Wf-  " 


?  /r  •':/  i  •//? 


Fig.   161. — Case  92,014.    Section  microphotograph,  lOOx,  tissue  from   stomach,      a, 
blood  vessels  with  thickened  walls;  b,  dense  connective  tissue;  c,  nest  of  phagocytes. 


228  SYPHILIS    OF   THE    STOMACH 

eat  solid  foods  without  discomfort,  and  that  his  weight  is  still  15  to  20 
pounds  below  normal. 

Case  94,732,  male,  aged  41.  Has  had  Neisser  infection  and  vene- 
real warts.  Denies  specific  infection.  About  two  years  ago  noticed 
loss  of  appetite  and  then  gradual  onset  of  heavy  feeling  in  epigastrium, 
relieved  by  vomiting  a  half  to  one  hour  after  eating.  With  this,  sour 
eructations  and  belching.  The  first  attack  lasted  three  or  four  months 
and  was  succeeded  by  a  free  interval  of  four  to  six  weeks.  Since  then 
the  trouble  has  been  fairly  continuous  though  worse  at  times.  Belches 
bitter  fluid,  mostly  at  night.     Eats  only  raw  eggs  and  milk  now,  but 


Fig.  162.— Case  94,732. 

recently  even  this  comes  up.  Weight  loss,  40  pounds.  Indefinite 
feeling  of  small  ridge  high  in  left  epigastrium.  Rectal  shelf  free. 
Hemoglobin  85.  Total  acids  12,  all  combined.  Wassermann:  Nega- 
tive twice;  strong  inhibition  twice.  Roentgen  findings:  Retention  of 
one-fourth  the  six-hour  meal.  Filling-defect  with  hour-glass  contrac- 
tion at  junction  of  pars  media  and  pars  cardiaca.  No  mass  correspond- 
ing to  defect.  The  narrowing  extends  well  down  to  the  pyloric  por- 
tion. Reflux  of  barium  meal  into  esophagus  which  is  somewhat  dilated 
(Fig.  162).  Diagnosis:  Carcinoma  or  syphilis.  Findings  at  opera- 
tion: Peculiar,  ruffled  condition  pyloric  end  and  body  of  stomach. 


REPORT    OF    CASES  229 

Apparently  a  series  of  ulcers  on  the  posterior  wall,  extending  nearly 
up  to  the  cardia.  The  stomach  is  narrowed  to  size  of  the  wrist. 
Portion  of  stomach  next  to  cardia  not  involved,  but  too  high  for 
gastro-duodenostomy.  No  glandular  involvement  but  some  adhesions 
posteriorly.  Does  not  seem  like  carcinoma  or  simple  ulcer;  appears 
rather  to  be  syphilitic.  Jejunostomy  for  feeding  purposes.  Anti- 
luetic  treatment  was  commenced.  Roentgenograms  by  Dr.  Tuohy 
four  months  after  operation  showed  practically  no  change  in  the  aspect 
of  the  stomach,  although  the  patient  had  improved  greatly  in  his 


Fig.  163. — Case  58,949.     First  examination. 

general  condition  and  had  gained  30  pounds.  A  year  after  operation 
the  patient  states  that  he  is  improved,  but  is  still  unable  to  take  solids 
without  distress. 

Case  58,949,  female,  aged  27.  Married,  two  children,  one  miscar- 
riage. Three  years  ago  she  developed  a  lump  on  the  right  chest-wall 
under  upper  right  quadrant  of  breast.  After  some  nine  months  tliis 
had  become  a  hard  fixed  tumor,  2}/^  by  4  inches,  and  projecting  \}4, 
inches  from  the  chest-wall.  This  was  incised  and  found  to  be  an 
abscess.  The  abscess  pocket  was  excised  and  necrotic  areas  of  rib 
curetted.  The  process  recurred  repeatedly,  was  curetted  again  and 
again,  and  finally  healed  about  a  year  ago  after  the  use  of  autogenous 
vaccines.     She    now    complains    of   a   gastric    trouble    which    began 


230 


SYPHILIS    OF   THE    STOMACH 


eighteen  months  ago,  consisting  of  fulhiess  immediately  after  meals  and 
epigastric  pain  two  hom^s  after  eating.  .  ]Milk  relieves  the  pain  tem- 
porarily; other  food  aggravates.  Little  weight  loss.  Patient  is 
anemic.  Hemoglobin  85,  total  acidity  10,  all  combined.  Wasser- 
mann,  total  inhibition.  Roentgen  findings:  First  examination  May 
22,  1914.     Report:  Indeterminate  (Fig.  163). 

Second  examination  Jiily  31,  1914.  Ko  retention  from  the  six- 
hour  meal.  Gaping  pylorus,  with  narrow,  concentrically  contracted 
stomach.  jS^o  palpable  mass  corresponding.  Evident  loss  of  flexi- 
bihty.     Peristalsis  not  seen  (Fig.  164).     Diagnosis:  Lesion  of  stomach. 


Fig.   164. — Case  58,949.     Second  examination,  nine  -n-eeks  after  first,  no  treatment 

having  been  given  as  yet. 

The  interesting  roentgenologic  feature  of  this  case  is  the 
marked  difference  between  the  findings  at  the  two  examinations, 
although  only  nine  weeks  had  elapsed,  and  shows  how"  rapidly 
the  process  progressed.  Treatment:  Salvarsan,  mercury,  io- 
dides. Four  months  later  the  patient  was  much  better  and  w^as 
able  to  eat  anything  without  distress.  At  the  end  of  a  year  she 
writes,  complaining  only  of  occasional  body-pains.  She  states 
that  her  husband  has  had  a  ''blood-test^'  and  that  he  has  the 
same  trouble  as  her  own. 


REPORT    OF    CASES 


231 


Case  81,986;  male,  aged  41.  Neisser  infection  in  youth;  no  evi- 
dence of  specific  lesion.  Almost  daily  stomach  trouble  for  three  years. 
Fifteen  minutes  to  an  hour  after  meals  he  has  had  distention,  belching, 
sour  eructations  and  frequently  vomiting.  Often  colicky  pains  over 
mid-abdomen  for  five  to  fifteen  minutes  at  any  time  of  day  with  no 
relation  to  food.  During  the  past  year  he  has  had  vomiting  immediately 
after  or  during  meals.  The  vomit  may  or  may  not  be  sour.  Diet 
is  not  a  factor.     No   dysphagia.     Weight  loss,   50   pounds.     Total 


Fig.   165— Case  81,986. 


acidity  10,  all  combined;  trace  of  food  remnants.  Wassermann 
strongly  positive.  Roentgen  findings:  No  retention  from  the  six- 
hour  meal.  Gross,  markedly  irregular  filling-defect,  involving  entire 
mid-portion  of  stomach.  Capacity  of  stomach  reduced.  No  palpable 
tumor  corresponding  to  defect.  Pylorus  gaping.  No  peristalsis 
seen  in  involved  area  (Fig.  165).  Diagnosis  (on  roentgen  findings 
only) :  Cancer  of  the  stomach. 


232  SYPHILIS    OF   THE    STOMACH 

Correlated  diagnosis  (from  roentgen,  clinical  and  laboratory  find- 
ings):  Syphilis  of  stomach.     Treatment:  Salvarsan,  etc. 

Subsequent  history:  Six  months  later  the  patient  could  eat  a  fair 
meal  without  distention  or  vomiting  and  had  gained  20  pounds.  Nine 
months  later  he  was  within  5  pounds  of  his  normal  weight  and  his 
complaints  were  few  and  trivial. 

Case  141,491,  female,  aged  30.  Married,  one  miscarriage  ten 
j^ears  ago.  About  six  years  ago  she  was  treated  for  syphilis  for  a  year 
and  a  half.  (This  statement  was  obtained  only  after  the  diagnosis 
had  been  made.)  About  eight  months  ago  she  began  to  be  troubled 
with  bloating  and  bitter  regurgitation,  aggravated  by  food.  For 
two  months  she  has  taken  only  infant  foods,  white  of  egg,  etc.  Weight 
loss,  51  pounds  in  6  months.  Hemoglobin  80.  Total  acidity  8,  all 
combined;  no  food  remnants.  Wassermann  strongly  positive.  Roent- 
gen findings:  Small  stomach  without  retention.  Hour-glass  contrac- 
tion pars  media.  Large  filling-defect  pjdoric  end  (Fig.  166).  Diag- 
nosis: Syphilis  or  cancer. 

The  patient  was  put  on  antiluetic  treatment,  salvarsan,  mercury 
inunctions,  iodides,  with  marked  improvement  clinically  and  anatom- 
ically as  shown  in  the  roentgenogram  (Fig.  167),  made  six  weeks  later. 
At  the  end  of  three  months  the  patient  had  gained  21  pounds,  and  was 
much  stronger. 

Case  94,691,  male,  aged  37.  Patient  had  gonorrhoea  several  years 
ago.  Chancre  (?)  eight  years  ago.  Wife  has  had  two  miscarriages. 
One  child  living  three  months  old.  Three  years  ago  the  patient  began 
having  pain  and  distress  in  the  epigastrium  during  or  immediately 
after  meals,  lasting  to  an  hour.  This  has  been  continuous  since, 
though  less  severe  at  times.  Occasional  sour  eructations  and  belch- 
ing. Says  skin  gets  yellowish  at  times.  Stool  light  in  color.  Weight 
loss,  45  pounds  in  three  years.  He  is  anemic  and  emaciated.  Skin 
negative.  Tenderness  right  costal  margin.  Supraclavicular  glands 
on  left  enlarged.  Hemoglobin  90.  Total  acidity  4,  all  combined. 
Wassermann,  total  inhibition.  Roentgen  findings:  First  examination: 
No  retention  from  the  six-hour  meal.  Filling-defects,  both  curvatures, 
extending  up  into  cardia.  Stomach  contracted  into  a  narrow,  irregular 
tube,  but  not  palpable.  Gaping  pylorus  (Fig.  168).  Diagnosis: 
Cancer  or  syphilis  of  the  stomach.  Treatment  with  salvarsan  was 
instituted.  Second  examination  (five  weeks  later) :  Condition 
unchanged.  Sixteen  months  later  the  patient  writes  that  he  has  gained 
19  pounds  in  weight,  has  a  good  color,  and  thinks  he  is  still  improving. 

Case  97,816,  male,  aged  33.  Gonorrhoea  in  youth;  now  has  stric- 
ture.    Appendectomy  and  cholecystectomy  eight  months  ago,  else- 


REPORT    OF    CASES 


233 


Fig.   166.— Case   141,491. 


Fig.  167. — Case  141,491.     Second  examination,  six  weeks  after  first. 


234 


SYPHILIS    OF   THE   STOMACH 


where.  Five  years  ago  began  having  attacks  of  sudden,  severe, 
epigastric  pain,  lasting  to  six  hours.  Intervals  free.  For  a  year  the 
pain  has  been  steady,  except  for  a  month  after  operation.  It  is  dull 
and  burning,  and  worse  with  a  full  stomach.  Occasional  sour  regurgi- 
tation. Irregular  vomiting  of  bile  and  food,  usually  on  rising.  Weight 
loss,  26  pounds.  Epigastric  tenderness  and  shght  resistance.  Wasser- 
mann,  total  inhibition.  Roentgen  findings:  First  examination,  De- 
cember 31,  1913:  No  retention  from  the  six-hour  meal.  Filling-defect 
and  hour-glass,  involving  pars  media  and  pylorica  (Fig.  169).     No 


Fig.  168.— Case  94,691. 


palpable  mass.  Diagnosis:  Ulcer  or  carcinoma  of  stomach.  A  corre- 
lation of  all  the  findings  indicated  the  probability  of  gastric  syphilis. 
Treatment:  Salvarsan,  mercury,  iodides.  Second  roentgen  examina- 
tion February  2,  1914:  Condition  unchanged.  After  two  months  of 
treatment  without  much  relief  the  patient  was  sent  to  operation, 
February  5,  1914.  Findings  at  operation:  Syphilitic  stomach;  lower 
third  involved.  Very  thick-walled  condition  without  limiting  margin. 
Adhesions  pylorus  and  duodenum  to  liver.  Anterior  gastro-enteros- 
tomy.  Third  roentgen  examination  February  20,  1914  (fifteen  days 
after  operation) :  Gastro-enterostomy  functionating.  Hour-glass  more 
pronounced,  lower  segment  being  almost  obliterated  (Fig.  170). 
Eighteen  months  later  the  patient  returned.     He  had  gained  35  pounds 


REPORT    OF    CASES 


235 


Fig.  169.— Case  97,816 


Fig.  170.— Case  97,816. 


236 


SYPHILIS    OF   THE    STOMACH 


in  'o-eight  and  stated  that  his  stomach  was  as  good  as  it  ever  was. 
Wassermann  negative. 

Case  100,618,  male,  aged  38.  Tj^phoid  at  15;  gonorrhoea  at  19. 
Sixteen  years  ago,  for  two  years,  was  addicted  to  morphine  and  cocaine. 
Took  drug  cm-e  and  has  touched  neither  since.  Two  years  ago  he 
began  having  a  little  epigastric  distress  a  few  minutes  to  an  hour  after 
meals.  A  year  ago  the  trouble  became  much  worse  and  came  imme- 
diately^ after  meals.  For  eight  months  he  has  had  attacks  of  vomiting 
every  two  or  three  daj^s.  Vomited  blood  four  weeks  ago.  Appetite 
good  but  afraid  to  eat  because  of  pain.  Latter  is  eased  only  bj"  vomit- 
ing, sometimes  induced.     Limited  diet  six  months.     Weight-loss,  50 


Fig.   171. — Case   100, dlS. 


pounds  in  past  year.  Tenderness  in  epigastrium.  Hemoglobin  85. 
Total  acids  12,  all  combined.  Roentgen  findings:  Large  stomach  wdth 
retention  of  half  the  six-hour  meal.  Prepjdoric  filling-defect  (Fig.  171) . 
No  palpable  mass.  Diagnosis:  Prepyloric  lesion.  Finding  at  opera- 
tion: LTcer  posterior  wall,  pyloric  end  of  stomach;  precancerous. 
Resection  hah  of  stomach.     Pathologist's  report:  LHcer. 

MacroscopicaUj',  the  resected  pjdoric  end  of  the  stomach  shows 
several  small  ulcers  and  a  few  raised  granulomatous  areas.  On  cross- 
section  these  areas  were  distincth''  raised.  Musculatm-e  apparently 
not  hj'pertrophic. 


REPOET    OF   CASES 


237 


--Cl 


Fig.  172, — Case  100,618.    Section  of  gastric  wall,  4x.      a,  floor  of  ulcer;  6,  intact 
mucosa;  c,  hypertrophied  submucosa;  d,  musculature. 


1- 


E5( 


-<i:  ^tS%  ^^"^'^'^  'U'Sf^'       Y4 


Fig.  173. — Case  100,618.    Section  of  tissue  from  stomach,  lOOx.      a,  vessel  showing 
obliterating  endarteritis;  b,  dense  connective  tissue-,  c,  mass  of  phagocytes. 


238 


SYPHILIS    OF    THE    STOMACH 


Fig.   178.  Fig.  179. 

Figs.  174,  17.5,  176,  177,  178,  179. — Gastric  syphilis. 


REFERENCES  239 

Microscopic  section,  4a;,  Fig.  172,  shows  ulcer  area  with  normal 
mucosa  at  border.  Marked  thickening  of  submucosa.  Musculature 
thickened  httle,  if  any. 

Microscopic  section,  lOO.r,  Pig.  173,  shows  an  increase  of  connective 
tissue  in  the  submucosa  which  is  many  times  its  normal  thickness. 
Numerous  blood-vessels,  large  and  small,  with  thickening  of  their  walls 
and  destruction  of  intima.  Many  blood-vessels  are  surrounded  by 
nodular  collections  of  large  round  cells  (phagocytes).  All  sections 
negative  for  malignancy.  Immediately  after  his  recovery  from  the 
operation,  a  Wassermann  test  was  made  and  this  was  found  to  be 
positive.  Accordingly,  the  patient  was  sent  to  his  home  with  instruc- 
tions to  take  antiluetic  treatment  by  his  family  physician.  Eight 
months  later  the  patient  wrote  that  he  was  much  improved.  No 
further  information  has  been  received. 

REFERENCES 

1.  Cronin,  M.  J.:  "The  Relation  of  Syphilis  to  Gastroenterological 

Diseases."     Interstate  Med.  Jour.,  1914,  xxi,  1019-1035. 

2.  Andral,  G.:  "Clinique   medicale."     4  ed.,    5v.  Paris,  Crochard, 

1839-1840. 

3.  Myer,  J.  S.:  ''Syphilis  of  the   Stomach  with   a  Heport  of  Two 

Cases  of  Syphilitic  Tumors."     Interstate  Med.  Jour.,  1912.  xix, 
974-979. 

4.  TuoHY,  E.  L.:  ''Contractures  of  the  Stomach."     Interstate  Med. 

Jour.,   1914,  xxi,  1036-1045. 

5.  Neumann,  I.:  "Syphilis."     Wien,  Holder,    1896,  v.  23   of  Noth- 

nagel.     Spec.  Path.  u.  Therap. 

6.  Penwick,  S.  andW.  S.:  "Cancer  and  Tumors  of  the  Stomach," 

London,  J.  and  A.  Churchill,  1902,  pp.  316. 

7.  Brugsch,    T.   and  Schneider,    E.:  "Syphilis    mit    Magensymp- 

tome."     Berl.  klin.  Wchnschr.,  1915,  lii,  601-606. 

8.  McNeil,  H.  L.:  "Syphilitic    Ulcer   of   the  Stomach."     Jour.  A. 

M.  A.,  1915,  Ixiv,  430. 

9.  DowNES,  W.  A.  and  Le  Wald,  L.  T.:    "Syphilis  of  the  Stomach." 

Jour.  A.  M.  A.,  1915,  Ixiv,  1824-1829. 

10.  Cornil,  a.  V. :  "Lecons  sure  la  syphilis,  faites  a  I'hospital  de  Lour- 

cine."     Paris,  Bailliere,  1879,  xii,  p  481. 

11.  BiRCH-HiRSCHFELD,  E.  V.:  Lehrbuch  der  pathologischen  Anato- 

mie."     3.    Aufl.  Leipzig,  Vogel,  1887,  ii,  518-537  and  589-1887. 

12.  EiNHORN,  M.:  "Syphilis  of  the  Stomach."     Phila.  Med.  Jour., 

1900,  V,  262-266. 


240  SYPHILIS    OF    THE    STOMACH 

13.  Faroy,  G.:  Comipt.  rend.  Acad.  d.  sc.  Par.,  1911,  cliii,  692. 

14.  Meyers^  J.:  "Syphilis  of  the  Stomach."     Albany  Med.  Ann., 

1912,  xxxiii,  563-589. 

15.  HoLiTSCH,  R. :  "Roentgen  Findings  in  a  Case  of  Syphihtic  Hour- 

glass   Stomach."     Trans.  Ninth  Congress,  German  Roentgen 
Society,  1913,  Buda-Pest,  51. 

16.  Christie,  A.  C:  "Studies  in  Roentgen-ray  Diagnosis  with  Espe- 

cial Reference  to  the  Gastro-intestinal   Tract."     Bull.  No.  7, 
War  Department,  Office  of  Surgeon  General,  1915,  22. 

17.  MuHLMANN,  E.:  "Beitrage  zum  Schrumpfmagen  auf  luetischer 

Basis."     Deutsch.  Med.  Wchnschr.,  xli,  733-734. 

18.  Mills,  R.  W. :  "Some  Points  of  Value  in  Roentgenoscopy  of  the 

Gastro-intestinal  Tract."     Jour.  A.  M.  A.,  1913,  Ixi,  1344-1350. 

19.  Morgan,  W.  G.:  "Syphilis  of  the  Stomach."     Amer.  Jour.  Med. 

Sci.,  1915,  cxlix,  392-406. 

20.  Brunner,  C:  "  Tuberculose,  Actinomycose,  Syphilis  des  Magen- 

darmkanals."     Billroth-Luecke,     Deutsche     Chirurgie,      xlvi. 
1907,  Stuttgart,  F.  Enke,  315-332. 


CHAPTER  XII 

VARIOUS   BENIGN   TUMOR-PRODUCING   LESIONS    OF  THE 

STOMACH 

Benign  tumors  of  various  kinds,  springing  from  the  wall  of 
the  stomach,  may  produce  filling-defects  in  its  lumen  and  other 
phenomena  which  cannot  be  distinguished  roentgenologically 
from  those  due  to  cancer.  While  not  of  frequent  occurrence, 
these  non-malignant  neoplasms  have  a  wide  range  of  histologic 
variance. 

CampbelP  mentions  as  among  the  more  important  the 
myomas,  fibromas,  adenopapillomas  and  lymphadenomas.  Less 
common,  he  states,  are  the  myxomas,  osteomas,  hydatid  cysts, 
serous  cysts,  blood-cysts  and  aneurysms.  Myomas,  fibromas 
and  adenomas  are  more  often  found  in  the  pyloric  portion  of 
the  stomach,  and  may  be  single  or  multiple.  Lipomas  are  usu- 
ally single  and  situated  on  the  anterior  wall  of  the  pars  media. 

Wade-  holds  that  the  majority  of  benign  tumors  ultimately 
come  to  project  within  the  gastric  chamber  and  become  pedun- 
culated, forming  polypi.  When  seated  near  the  pylorus  they 
may  produce  pyloric  obstruction  by  their  ball-valve  effect. 
More  often  single  and  attached  to  any  part  of  the  gastric  mucosa, 
polypi  are  sometimes  multiple  and  occasionally  so  numerous 
that  the  term  ''polyposis"  is  applicable.  Sherren^  has  collected 
several  cases  of  polypoid  tumors  attached  to  the  outside  of  the 
stomach. 

According  to  Campbell,  the  only  example  of  dermoid  cyst 
that  has  heretofore  been  observed  in  the  stomach,  was  reported 
by  Ruysch  in  1732.  It  consisted  of  a  small  tumor  of  the  gastric 
wall  which  contained  hair.  A  case  of  desmoid,  a  hard,  fibrous 
tumor,  has  been  published  by  Gray  and  Nesselrode.^ 

Nassetti^  found  smooth  muscle-tumors  in  the  stomach  at 

16  241 


242  TUMOR-PRODUCING    LESIONS    OF   THE    STOMACH 

necropsy  in  7  instances.  He  reviews  the  similar  cases  on  record, 
of  which  he  has  compiled  140. 

Basch'^  gives  the  usual  list  of  non-malignant  gastric  neo- 
plasms, and  furnishes  brief  histories  of  3  cases  with  the  roent- 
genologic findings,  which  are  excellently  illustrated.  One  was 
a  papillary  adenoma,  the  size  of  a  walnut,  attached  to  the  lesser 
curvature  near  the  pylorus.  It  gave  a  persistent  filling-defect 
in  the  roentgenogram.  Another  was  a  pedunculated  mass  about 
23>^  inches  in  diameter,  attached  to  the  anterior  wall,  as  found  at 
exploration.  It  produced  a  spherical  central  filling-defect  at 
the  junction  of  the  antrum  and  pars  media.  On  account  of  the 
patient's  condition  it  could  not  be  removed,  and  its  exact  nature 
was  not  determined.  In  the  third  case  there  were  two  papillo- 
adenomas,  one  ^^  inch,  the  other  1^  inches  long,  attached  to 
the  posterior  wall  3  inches  from  the  pylorus.  They  produced 
finger-print-like  filling-defects  in  the  screen-image  and  roent- 
genogram, and  were  centrally  located  in  the  antrum.  Hyper- 
motility  and  hyperperistalsis  were  also  noted. 

A  neoplastic  form  of  tuberculosis  of  the  stomach,  more 
often  affecting  the  pyloric  portion,  is  occasionally  noted. 

Aside  from  actual  neoplasms,  the  gastric  lumen  may  rarely 
be  intruded  upon  by  varicosities,  by  a  phlegmon  in  the  gastric 
wall,  or  by  a  local  hypertrophy  of  the  musculature  such  as  occurs 
in  benign  thickening  of  the  pyloric  ring.  Syphilitic  gummata, 
infiltrations  and  fibromatosis  have  been  discussed  elsewhere. 

While  all  the  conditions  enumerated  should  be  kept  in  mind 
by  the  roentgenologist  as  possibilities  in  cases  showing  an  evi- 
dent tumor  of  the  stomach,  it  should  equally  be  remembered 
that  the  chance  of  their  existence  is  relatively  small.  Few  of 
them  have  been  examined  by  the  roentgen-ray,  and  no  general 
conclusions  as  to  their  roentgen  manifestations  can  be  drawn 
from  this  scant  material. 

The  case  of  polyposis  reported  by  Myer^  illustrates  both  the 
clinical  and  roentgenologic  aspects  of  the  condition.  The  ob- 
servation of  this  case  extended  over  a  period  of  eight  years. 
The   patient's  antecedent  history  was  indicative  of  syphilis. 


POLYPOSIS  243 

When  seen  jfirst  in  1904  he  was  complaining  of  abdominal  dis- 
tress one  or  two  hom^s  after  meals  and  had  lost  weight  rapidly. 
Examination  of  the  gastric  contents  showed  achylia,  lactic  acid 
and  mucus.  Subsequently  the  amount  of  mucus  became  ex- 
traordinarily large.  Five  years  later,  while  being  subjected  to 
lavage,  a  polyp  the  size  of  a  pea  was  expressed  through  the  tube 
and  upon  microscopic  examination  was  found  to  be  a  simple 
benign  adenoma.     In  1912  the  patient  had  severe  hematemesis. 


Fig.  180. — Gastric  polyposis. 

Upon   physical   examination,   resistance   was   found   over   the; 
pylorus  and  peristalsis  was  visible. 

Fluoroscopic  and  roentgenographic  examinations  by  one  of  us 
(Carman)  revealed  an  almost  total  obliteration  of  the  pars  py- 
lorica  and  distal  pars  media.  The  main  bismuth  mass  lay  to  the 
left  of  the  vertebral  column  and  had  an  irregular,  indefinite  con- 
tour. Small  amounts  of  bismuth  trickling  through  the  right  half 
of  the  stomach  gave  it  a  mottled  appearance  and  suggested 
irregular  masses  projecting  from  the  gastric  wall.     The  motility 


244 


TUMOR-PRODUCING    LESIONS    OF   THE    STOMACH 


of    the    stomach   was    not    tested    by    the   roentgen    method 
(Fig.  180). 

Operation:  Gastrotomy.  Gastric  mucosa  hterally  covered 
from  the  cardia  to  within  an  inch  of  the  pylorus  with  pedicled 
polypi  (Fig.  181).  Excision  of  one  large  pedunculated  papillo- 
matous tumor,  the  size  of  a  fist,  attached  3  inches  above  pylorus. 


Fig.  181. — Gastric  polyposis.  Photograph  of  stomach  removed  post  raortem,  show- 
ing the  entire  mucosa,  with  the  exception  of  a  small  area  near  the  cardiac  orifice,  liter- 
ally covered  with  polyps;  a,  a  large  grapelike  bunch  of  polyps,  a  portion  of  which  had 
invaginated  the  pylorus. 


Microscopic  section  of  the  polyp  showed  that  its  chief  mass  con- 
sisted of  hypertrophied  mucosa,  with  immensely  hypertrophied 
glands.  Small  cysts  were  noted  in  various  parts  of  the  stomach. 
In  addition  to  Myer's  case,  our  own  experience  has  included 
instances  of  dermoid  cyst,  fibromyoma,  hypertrophy  of  the 
pyloric  ring  and  tuberculosis.     The  case  histories  follow. 


REPORT    OF    CASES 


245 


Case  136,147;  boy  aged  8.  About  four  years  ago  the  parents 
noticed  a  small  lump  in  his  abdomen,  which  seemed  to  be  more  promi- 
nent at  times,  especially  when  standing.  The  lump  has  grown  gradually 
and  has  been  quite  marked  during  the  past  six  months.  Aside  from 
some  urinary  frequency,  the  patient  has  no  symptoms.  Hemoglobin 
70.  Large,  freely  movable,  not  tender,  mass  filling  upper  and  central 
abdomen.  Roentgen  findings:  No  retention  from  the  six-hour  meal. 
Stomach  very  high,  occupying  a  transverse  position.     The  displace- 


FiG.   182. — Case  136,147. 

ment  upward  is  due  to  a  large  palpable  tumor  which  is  extrinsic  and 
does  not  deform  the  gastric  lumen  (Fig.  182).  Finchng  at  operation: 
Gourd-shaped  tumor  attached  to  posterior  wall  of  stomach  and  pro- 
jecting into  the  lesser  cavity  of  the  peritoneum.  Tumor  larger  than 
the  stomach  itself.  Resection  of  area  of  attachment.  Pathologist's 
report:  Dermoid  cyst  (Fig.  183).     Weight  1000  gm. 

Case  142,665,  female,  aged  65.  Operation  elsewhere  four  years  ago 
for  the  removal  of  gall-stones.  Soon  afterward  she  discovered  a  mov- 
able mass  in  the  epigastrium  and  began  to  have  attacks  of  sharp  epi- 
gastric pain,  coming  at  any  time,  and  vomiting  immediately  after 
meals.  The  present  attack  has  lasted  six  weeks.  Weight  loss,  50 
pounds  in  three  j^ears.  Nodular  tumor  can  be  felt  in  left  epigastrium. 
Hemoglobin  44.     Total  acidity  6;  all  combined.     Roentgen  findings: 


246 


TUMOR-PRODUCING    LESIONS    OF    THE    STOMACH 


No  retention.  Extensive  filling-defect  involving  pars  pylorica  and 
media,  and  part  of  cardia.  Slight  hindrance  to  entrance  of  barium 
through  esophageal  opening  (Fig.  18i).  Diagnosis:  Carcinoma; 
inoperable.  (To  tliis  report  the  examiner  added  the  statement  that 
the  filling-defect  was  very  unusual.)  Findings  at  operation:  Timior 
posterior  wall  of  stomach,  3  inches  above  pylorus,  the  size  of  a  small 
orange.     The  tumor  has  invaginated  through  the  pylorus  into  the 


Fig.  183.— Case  1.36,147.     Dermoid  cj-st. 

duodenum.     Exsection  of  tumor  and  area  of  attachment.     Patholo- 
gist's report :  Fibromj'oma. 

Case  80,723,  female,  aged  29.  Ten  years  ago  she  began  to  have 
attacks  each  spring  of  indigestion,  but  would  be  entirely  well  the  rest 
of  the  year.  Four  years  ago  the  trouble  became  worse;  after  each 
meal  she  would  have  epigastric  burning,  vomiting,  and  gas  distention. 
Food  gives  relief  but  is  vomited.  The  attacks  last  for  weeks,  with 
intervals  of  perfect  health.     During  the  past  year  the  pain  has  fre- 


REPORT    OF    CASES 


247 


Fig.  1S4. — Case  142,665. 


Fig.  185. — Case  80,723. 


248  TUMOE-PRODUCING    LESIONS    OP    THE    STOMACH 

quently  been  severe  and  cramp-like,  hypodermatic  injections  being 
given  for  relief.  Total  acidity  30;  all  free.  Epigastric  tenderness. 
Roentgen  findings:  Retention  of  half  the  six-hour  meal.  Hypotonic, 
low-lying  stomach  with  strong  peristalsis.  Prepyloric  narrowing  seen 
on  the  screen.  Diagnosis:  Pyloric  obstruction.  The  roentgenogram, 
Fig.  185,  does  not  show  the  lesion,  due  to  the  fact  that  the  plate  was 
made  with  the  patient  standing  and  the  barium  has  settled  away  from 
the  area  involved.  The  case  illustrates  the  necessity  of  making  at 
least  some  of  the  plates  in  the  prone  position.  Findings  at  operation: 
Great   thickening   of   pylorus,   feeling  like   a   tumor.     Much   thick, 


Fig.   186. — Case  152,198. 

ascitic  fluid  in  abdomen.  Edematous  thickening  of  upper  jejunum 
with  many  enlarged  glands  in  mesentery.  Resection  4  inches  pyloric 
end.  Anterior  gastro-enterostomy.  Pathologic  report :  Hypertrophy 
of  muscular  and  mucous  layers  of  stomach;  14  mm.  at  pylorus.  Small 
adenomatous  polyp  near  pylorus.  Marked  hypertrophy  of  annular 
fibers  of  pylorus,  with  the  opening  narrowed  to  about  5  mm.  Glands 
from  mesentery  inflammatory. 

Case  152,198,  male,  aged  42.  Two  years  ago  he  first  noticed 
epigastric  heaviness  and  distress  immediately  after  meals.  After  a 
few  months  he  began  having  attacks  of  vomiting  two  or  three  hours 
after  meals.     Six  months  ago  the  attacks  of  vomiting  became  more 


TUBERCULOSIS    OF   STOMACH  249 

frequent  and  as  early  as  a  half  hour  after  meals.  Surgical  exploration 
(elsewhere)  revealed  what  was  considered  to  be  an  inoperable  cancer  of 
the  stomach.  Following  this  operation  the  patient  improved  some- 
what until  three  weeks  ago,  since  which  time  the  vomiting  has  been 
worse,  food  being  rejected  as  soon  as  taken.  Normal  weight  135; 
present  100.  Palpable  mass  in  right  abdomen,  thought  to  be  kidney. 
No  epigastric  mass.  Hemoglobin  70.  Total  acidity  12,  all  combined ; 
food  remnants;  Oppler-Boas  bacilli.  Roentgen  findings:  Retention 
of  three-fourths  of  the  meal  at  the  end  of  six  hours.  Hour-glass  con- 
tracture of  stomach  in  pars  media  with  some  irregularity  of  contour. 
Pars  pylorica  replaced  by  a  filling-defect  (Fig.  186).  Diagnosis: 
Cancer;  operable.  Findings  at  operation:  Tumor  of  stomach  near 
pylorus.  Marked  spasm;  stomach  not  dilated.  Resection  about 
one-third  of  stomach.  Pathologist's  report:  Tuberculosis  of  stomach 
and  glands. 

REFERENCES 

1.  Campbell,  A.   M. :  "Benign  Tumors  of   the    Stomach."      Surg., 

Gynec.  and  Ohstet.,  1915,  xx,  66-71. 

2.  Wade,  H.:  "Intussusception  of  the  Stomach  and  Duodenum  due 

to  a  Gastric  Polypus."     Surg.,  Gynec.  and  Ohstet.,  1913,  xvii, 
184-190. 

3.  Sherken,    J.:    "External    Polypoid    Tumors    of    the    Stomach." 

Brit  Med.  Jour.,  1911,  ii,  593. 

4.  Geay,  G.  M.  and  Nesselrode,  C.  C:  "Report  of  a  Case  of  Des- 

moid of  the  Stomach,  Etc."     Jour.  Kansas  Med.   Soc.,  1911, 
xi,  498-505. 

5.  Nassetti,  F.:  "  Smooth  Muscle-tumors  in  the  Stomach."    Tumori 

(Rome),  1914,  iv.  No.  3.     Abstr.  Jour.  A.M.  A.,  1915,  Ixiv,  867. 

6.  Basch,  S.:  "Primary  Benign  Growths  of  the  Stomach."      Surg., 

Gynec.  and  Ohstet.,  1916,  xxii,  165-170. 

7.  Myer,J.S.:  "Polyposis  gastrica (Pol yadenoma)."     Jour.  A.  M.  A., 

1913,  Ixi,  1960-1965. 


CHAPTER   XIII 
GASTRIC  ULCER 

The  succession  of  events  in  developing  the  roentgenologic 
diagnosis  of  gastric  ulcer  has  been  orderly,  and  few  steps  have 
been  taken  which  had  to  be  retraced.  Even  Hemmeter's^  effort 
to  demonstrate  the  site  of  an  ulcer  by  the  adherence  of  a  fleck 
of  bisrauth  was  not  so  far  beside  the  mark.  Though  impractical 
in  its  original  appUcation,  his  employment  of  an  opaque  salt 
and  the  roentgen-ray  had  its  influence  in  stimulating  others  to 
more  successful  attempts. 

With  the  advent  of  the  Rieder  meal,  the  Continental  roent- 
genologists were  able  to  find  the  more  striking  secondary  mani- 
festations of  gastric  ulcer,  notably  hour-glass  deformity,  and 
gave  heed  to  six-hour  retention  and  other  general  indications  of 
gastric  pathology.  Then  Reiche  succeeded  in  demonstrating 
the  cavity  of  an  ulcer,  and  Hemmeter's  dream  came  true. 
With  additional  experience  it  became  possible  to  differentiate 
secondary  gastric  phenomena  produced  by  an  intrinsic  cause 
from  those  due  to  an  extrinsic  cause,  and  to  combine  the  former 
with  chnical  data  into  practical  syndromes. 

At  its  present  stage  the  accuracy  of  the  roentgen  diagnosis  of 
gastric  ulcer  is  greater  than  is  generally  appreciated,  and  con- 
siderably exceeds  that  of  customary  clinical  methods.  It 
would  seem  that  in  the  opinion  of  some  gastroenterologists  the 
usefulness  of  the  roentgen-ray  in  this  connection  is  Hmited  in 
the  main  to  differentiating  gastric  from  duodenal  ulcer.  How- 
ever, they  thus  unwittingly  concede  its  absolute  value  in  the 
diagnosis  of  either  condition.  We  are  also  obliged  to  dissent 
from  the  assumption  that  the  clinical  examination  is  quite 
sufficient  to  confirm  or  negate  the  presence  of  an  ulcer,  though 
it  may  not  be  able  to  fix  its  site. 

250 


TYPES    OF   ULCER  251 

From  our  own  statistics  we  can  say  that  nine-tenths  of  the 
ulcers  of  the  stomach  give  distinct  roentgenologic  indications  of 
gastric  disease,  and  in  an  overwhelming  majority  of  these  the 
roentgen  signs  are  either  pathognomonic  or  strongly  presump- 
tive of  ulcer. 

From  a  gross  and  microscopic  study  of  445  cancers  of  the 
stomach,  Wilson  and  McDowelP  regard  it  as  probable  that 
gastric  cancer  rarely  develops  except  at  the  site  of  a  previous 
ulcerative  lesion  of  the  mucosa.  While  this  should  not  be 
misconstrued  as  saying  that  all  ulcers  become  carcinomatous, 
it  does  indicate  that  many  ulcers  are  potential  cancers.  Hence, 
the  advantage  of  an  exact  diagnosis  of  gastric  ulcer,  as  afforded 
by  the  roentgen-ray,  is  apparent. 

As  seen  at  operation,  four  classes  of  gastric  ulcer  may  be 
distinguished: 

1.  Small,  exceedingly  shallow,  mucous  erosions  and  minute 
slit-like  ulcers. 

2.  Penetrating  or  callous  ulcers  with  relatively  deep  craters. 

3.  Perforating  ulcers,  with  or  without  the  production  of 
an  accessory  cavity. 

4.  Carcinomatous  ulcers. 

Of  these  four  classes,  the  first — the  small,  shallow,  mucous 
erosions — offer  the  greatest  difficulty  to  roentgenologic  detec- 
tion. They  are  either  superficial  denudations,  or  mere  slits 
in  the  mucosa,  incapable  of  holding  enough  barium  to  make  a 
visible  projection  from  the  gastric  lumen.  Unless  accompanied 
by  secondary  roentgen  phenomena,  such  as  the  incisura  and  six- 
hour  retention,  their  presence  is  not  likely  even  to  be  suspected. 

The  penetrating  ulcers  which  have  burrowed  more  or  less 
deeply  into  the  gastric  wall,  produce  a  definite  crater  jutting 
out  from  the  lumen  of  the  stomach.  The  degree  of  facility 
with  which  this  crater  can  be  seen  by  the  roentgen-ray  depends 
more  on  its  location  than  its  size. 

Perforation  of  an  ulcer,  with  a  continuation  of  the  destruc- 
tive process  into  adjacent  tissues,  results  in  the  formation  of  an 
accessory  cavity  outside  the  stomach.     Such  a  cavity  can  nearly 


252  GASTRIC   ULCER 

always  be  seen,  both  on  screen  and  plate.  Perforation  may, 
of  course,  occur  without  any  excavation  of  the  tissues  beyond 
the  stomach.  In  this  event  the  roentgen-ray  should  show  the 
ulcer-crater,  plus,  in  some  instances,  the  distorting  effect  of 
adhesions. 

Early  carcinomatous  ulcers  are  not,  as  a  rule,  distinguishable 
from  non-malignant  ulcers,  their  roentgenologic  signs  being  the 
same  as  those  of  penetrating  or  perforating  ulcer. 

ROENTGENOLOGIC  SIGNS  OF  GASTRIC  ULCER 

The  roentgen  signs  of  ulcer  may  be  divided  into  (1)  those 
which  are  primary  and  practically  pathognomonic,  and  (2) 
those  which  are  secondary  and  corroborative,  but  not  absolutely 
diagnostic. 

The  first  class  comprises  two  signs,  namely,  the  niche  and 
the  accessory  pocket. 

The  second  class  includes: 

Spastic  manifestations: 

(a)  The  incisura. 

(6)  Spasmodic  hour-glass  stomach. 

(c)   Diffuse  gastrospasm. 

Organic  hour-glass  stomach. 

Retention  from  the  six-hour  meal. 

Gastric  hypotonus. 

Acute  fish-hook  form  of  the  stomach. 

Alterations  of  peristalsis. 

Localized  tenderness. 

Lessened  mobility  of  the  stomach. 

The  Niche. — For  convenience  we  shall  Umit  the  application 
of  this  term  to  the  visualized  crater  of  a  penetrating  ulcer,  the 
cavity  of  which  lies  entirely  in  the  wall  of  the  stomach.  The 
first  to  show  definitely  the  projection  of  a  bismuth-filled  ulcer- 
crater  from  the  gastric  lumen,  was  Reiche."  Later,  Haudek'^ 
called  it  the  ''nischen-symptom"  and  applied  it  to  every  form 
of  recess  produced  by  an  ulcer,  whether  penetrating  or  per- 
forating. 


THE    NICHE 


253 


The  niche  shows  as  a  bud-hke  prominence  on  the  peripheral 
outline  of  the  stomach  (Fig.  187).  It  is  often  regularlj^  cres- 
centic,  but  may  be  irregularly  shaped.  Its  size  may  vary  from 
a  mere  fleck  to  a  considerable  protuberance.  It  is  worthy  of 
note  that  a  niche  may  be  demonstrable  even  though  the  ulcer 
has  not  penetrated  very  deeply  (Fig.  188).  As  an  ulcer  may 
occur  in  any  part  of  the  stomach,  it  follows  that  the  niche  may 
also  be  found  anywhere.  By  far  the  larger  number,  however, 
are  noted  either  on  the  lesser  curvature,  usually  above  the 


Fig.   187. — Barium-filled  crater  of  gastric  ulcer  at  a. 

incisura  angularis,  or  on  the  posterior  wall  near  the  lesser  cui;\'a- 
ture.  When  situated  upon  the  vertical  portion  of  the  lesser 
curvature,  a  niche  will  usually  show  plainly  in  the  antero- 
posterior view.  If  located  on  the  posterior  wall  of  the  vertical 
portion  of  the  stomach,  an  oblique  view  is  often  necessary  to 
discover  it.  When  the  niche  is  seated  on  the  lesser  curvature 
of  the  pyloric  portion,  it  may  be  hard  to  distinguish.  Quite 
often  an  ulcer  in  the  pyloric  portion  is  on  the  posterior  wall  and 
detection  of  the  niche  is  hampered  by  the  difficulty  of  obtaining 


254  GASTRIC    ULCER 

any  but  an  anteroposterior  view.  A  small  niche  in  any  situation 
may  be  hidden  or  partially  obliterated  when  the  stomach  is 
distended,  so  that  careful  observation  should  be  made  while 
the  stomach  is  filling,  especially  while  the  patient  is  drinking 
the  aqueous  mixture  (Fig.  189).  The  niche  accompanies  the 
gastric  wall  in  its  movements,  whether  by  palpation  or  respira- 
tion.    It  fills  and  empties  directly  with  the  stomach. 


Fig.  188. — Gastric  ulcer  at  a.     Note  that  the  crater  is  not  deep, 

A  small  collection  of  barium  in  the  bowel  adjacent  to  the 
gastric  outline,  especially  the  lesser  curvature,  may  superficially 
imitate  a  niche,  but  manipulation  will  readily  show  the  differ- 
ence. The  bulge  between  two  peristaltic  waves  close  together 
on  the  lesser  curvature  often  looks  very  much  like  a  niche. 
Conversely,  a  true  niche  may  be  mistaken  for  this  bulge.  How- 
ever, as  the  waves  progress,  the  bulge  moves  toward  the  pylorus, 
while  a  niche  remains  stationary,  so  that  a  little  study  of  the 
screen-image  will  easily  make  the  distinction. 


THE    NICHE 


255 


Fig.  189. — Gastric  ulcer  with  high  hour-glass,  persistent  after  belladonna.  In  this 
instance  a  small  niche  in  the  plane  of  the  hour-glass  constriction  was  noted  at  each 
examination  while  the  patient  was  drinking  the  barium-water  mixture,  but  could  not  be 
seen  after  filling  the  stomach. 


Fig.  190. — Accessory  cavity  due  to  perforating  ulcer  at  a- 


256  GASTEIC    ULCER 

Accessory  Pocket. — The  accessory  pocket,  as  previously 
stated,  occurs  as  the  result  of  perforation  of  an  ulcer  and  exten- 
sion of  the  ulcerative  process  into  adjoining  structures,  produc- 
ing a  cavity  (Fig.  190).  If  situated  high  up,  ulcers  of  the  lesser 
curvature  or  anterior  wall  are  apt  to  perforate  against  or  into 
the  liver,  while  those  lower  down  and  on  the  posterior  wall  are 
more  likely  to  invade  the  pancreas.  Instances  have  also  been 
noted  of  perforation  between  the  layers  of  the  lesser  omentum, 
into  the  anterior  abdominal  wall,  and  into   the   spleen. 

We  have  purposely  avoided  using  the  term  ''diverticulum" 
generally  employed  by  roentgenologists  to  describe  the  cavity 
formed  by  a  perforating  ulcer.  In  a  strict  anatomo-pathologic 
sense  a  diverticulum  must  have  the  same  lining-cells  as  the  vis- 
€us  from  which  it  springs.  Inasmuch  as  an  ulcer  begins  with 
destruction  of  these  cells,  the  production  of  a  diverticulum  by 
an  ulcer  is  hardly  possible. 

When  visualized  by  the  barium  meal  the  contents  of  the 
pocket  are  stratified  like  those  of  the  stomach;  the  opaque 
barium  at  the  bottom  has  a  translucent  layer  of  fluid  above  it, 
and  this  in  turn  is  capped  by  a  small  gas-bubble. 

Accessory  pockets  range  in  diameter  from  1  to  5  cm.  or 
more.  They  are  usually  spherical  in  outline,  but  may  be  irregu- 
larly shaped.  A  pocket  in  the  liver  moves  with  respiration, 
while  one  in  the  pancreas  does  not,  and  a  more  anterior  situa- 
tion of  the  former  may  be  shown  by  an  oblique  view.  If  within 
reach,  a  pocket  is  commonly  immovable  by  palpatio  q  and  tender 
to  pressure.  The  canal  joining  it  to  the  gastric  cavity  may  or 
m.ay  not  be  distinctly  visualized  by  the  barium.  Barium 
remains  in  the  pocket  when  the  gastric  contents  settle  to  the 
lower  pole  of  the  stomach,  and  this  feature  distinguishes  a 
pocket  from  a  niche. 

A  six-hour  rest  in  the  stomach  is  often  associated  with  an 
accessory  pocket.  Organic  hour-glass  stomach  sometimes  ac- 
companies an  accessory  cavity,  but  not  invariably. 

If  the  stomach  is  acutely  flexed,  the  beginner  may  at  first 
mistake  a  partly  filled  duodenal  bulb  for  an  accessory  pocket. 


CONTRIBUTORY    SIGNS    OF    ULCER  257 

and  he  should  be  careful  to  exclude  this  possibility.  A  true 
diverticulum  of  the  stomach,  most  often  a  congenital  anomaly, 
might  be  mistaken  for  the  excavation  of  an  ulcer,  either  pocket 
or  niche,  but  this  condition  is  exceedingly  rare. 

Contributory  Signs  of  Ulcer. — To  produce  either  a  niche  or 
accessory  pocket  it  is  plainly  necessary  that  the  ulcer  shall 
have  eroded  the  gastric  wall  to  a  depth  sufficient  to  make  a 
demonstrable  projection  from  the  gastric  lumen.  While 
this  occurs  in  the  majority  of  the  cases  examined,  there  remains 
a  large  number  of  cases  in  which  the  ulcer  is  so  shallow  that  no 
excavation  can  be  detected.  In  these,  if  a  roentgen  diagnosis 
can  be  made  at  all,  it  must  be  based  on  indirect  phenomena. 

Spasmodic  Manifestations — The  Incisura. — Chief  among 
the  spasms  excited  by  ulcer  and  perhaps  the  strongest  contribu- 
tory sign  of  this  lesion,  is  the  incisura.  Exploited  early  as  a 
practical  roentgenologic  indication  of  ulcer,  it  has  been  given 
abundant  attention  in  the  literature,  possibly  more  than  it 
deserves,  since  it  occurs  in  only  a  small  percentage  of  cases. 

The  incisura  is  an  indentation  of  the  gastric  wall  opposite  an 
ulcer  (Fig.  191).  Its  production  is  generally  believed  to  be  due 
to  irritation  of  the  ulcer,  causing  a  spastic  contraction  of  the 
circular  muscle-fibers  in  its  plane.  An  incisura  may  also  occur 
in  association  with  the  scar  of  a  healed  ulcer.  Theoretically,  it 
may  occur  anywhere  in  the  stomach  and  be  seen  on  either  curva- 
ture. However,  we  have  never  observed  one  on  the  lesser  curva- 
ture. Practically,  the  vast  majority  are  found  on  the  greater 
curvature,  and  most  commonly  in  the  vertical  portion  of  the 
stomach.  Occasionally  they  may  be  noted  in  the  pyloric  portion 
(Fig.  192). 

Incisurse  have  considerable  variation  as  to  width  and  depth. 
They  may  be  so  deep  as  almost  to  bisect  the  stomach,  or  so  shal- 
low as  merely  to  dimple  the  curvature.  The  angle  of  view,  of 
course,  affects  the  apparent  depth.  The  outline  of  an  incisura  is 
commonly  sharp  and  regular,  but  occasionally  some  irregularity 
may  be  noted.  Each  of  two  or  more  ulcers,  even  though  closely 
situated,  may  have  its  separate  incisura. 

17 


258 


GASTRIC    ULCER 


Fig.   191. — Incisura  at  b,  opposite  gastric  ulcer  a. 


Fig.  192. — Prepyloric  incisura  at  a  which  was  permanent.  No  visible  niche/marked 
dilatation  of  first  part  of  duodenum,  with  irregularity  of  superior  wall  at  b.  Diagnosis: 
Prepyloric  ulcer  with  adhesions  obstructing  duodenum. 


SPASTIC    MANIFESTATIONS  259 

Recognition  of  an  incisura  is  not  difficult  as  a  rule.  The 
stomach  should  be  watched  during  the  process  of  filling;  after 
repletion  an  incisura  may  be  more  or  less  concealed  by  over- 
lapping of  its  borders.  Overlapping  may  be  so  marked  that 
gentle  pressure  is  necessary  to  visualize  the  indentation.  The 
patient  should  be  turned  about  to  permit  oblique  or  lateral  in- 
spection of  the  gastric  contour.  An  incisura  high  up  in  the  ver- 
tical portion  of  the  stomach  may  lie  wholly  in  the  fluid  zone 
above  the  opaque  meal  and  thus  escape  notice.  Occasionally 
a  little  barium  may  settle  above  the  incisura,  as  upou  a  shelf, 
but  the  incisura  will  not  be  clearly  visible  as  such  unless  the 
opaque  meal  surrounds  it.  Hence  the  barium  should,  if  nec- 
essary, be  forced  upward  by  manipulation  during  the  vertical 
screen-examination,  and  plates  should  be  made  in  the  prone 
position.  Incisurse  in  the  pars  pylorica  are  usually  small,  and 
this  region  should  be  studied  closely. 

True  incisurse  must  be  differentiated  from  the  normal  incis- 
ura angularis  and  incisura  cardiaca,  from  the  occasional  inden- 
tation of  the  greater  curvature  where  the  left  costal  arch  crosses 
it,  from  the  effect  of  adhesion-bands,  and  from  spasmodic  incis- 
urse arising  from  causes  outside  the  stomach. 

The  normal  incisura  angularis  in  the  angle  of  the  lesser  curva- 
ture, and  the  incisura  cardiaca  at  the  junction  of  the  esophagus 
with  the  stomach  should  be  familiar '  to  the  roentgenologist. 
Slightly  less  familiar  is  an  indrawing  of  the  greater  curvature 
beneath  the  left  costal  arch,  produced  either  by  the  pressure  of 
the  arch  or  by  tension  of  the  abdominal  muscles.  Commonly 
this  indentation  is  broad,  shallow,  and  obviously  not  an  incisura. 
However,  the  depression  may  be  so  narrow  and  sharp  that  the 
observer  is  uncertain.  Pushing  up  the  lower  pole  of  the  stom- 
ach tends  to  narrow  and  deepen  the  indentation  and  thus  add  to 
the  uncertainty.  In  fact,  this  sort  of  manipulation  may  easily 
produce  an  apparent  incisura  in  almost  any  stomach  and  should 
be  avoided.  Palpatory  pressure  should  be  directly  backward 
and  not  upward  if  an  incisura  is  being  sought. 

An  adhesion-band  may  constrict  the  stomach  in  such  fashion 


260 


GASTRIC    ULCER 


as  to  simulate  an  incisura.     Fig.  193  represents  such  an  instance, 
the  onty  one  that  we  have  encountered. 

The  most  annoying  imitations  of  true  incisurse  are  those 
produced  by  extrinsic  spasms,  that  is  to  say,  spasm  excited  by 
causes  outside  the  stomach.  Such  incisurse  are  often  associated 
with  disease  of  the  gall-bladder  or  appendix,  or  with  duodenal 


Fig.  193.— Incisura  at  a,  persistent  at  a  second  examination  after  belladonna. 
Diagnosis:  Ulcer  of  stomach.  Operation:  Xo  ulcer.  Hour-glass  due  to  adhesion 
band. 


ulcer.  These  reflex  incisurse  frequenth^  have  an  appearance  and 
position  identical  with  true  incisurse.  They  may  be  stationary 
or  migratory.  Their  reflex  spasmodic  character  is  evident  if 
they  move  toward  the  pylorus.  Even  though  stationarj^,  they 
may  be  assumed  to  have  an  extrinsic  cause  if  they  relax  and  dis- 
appear upon  massage  or  after  the  administration  of  an  anti- 
spasmodic. The  opinion  has  been  advanced  that  non-per- 
manent incisurse  maj^  sometimes  be  caused  by  shallow  erosions 
but  decisive  proof  of  this  is  lacking  as  yet. 


SPASMODIC    HOUR-GLASS  261 

It  follows  that  a  true  incisura  must  be  subjected  to  and 
withstand  the  following  tests: 

It  must  be  constant  and  stationary. 

It  must  be  present  when  the  stomach  hangs  in  its  natural 
position. 

It  must  survive  manipulation. 

It  must  persist  after  the  patient  has  been  given  an  antispas- 
modic to  physiologic  effect. 

Spasmodic  Hour-glass. — Any  stomach  which  is  indented  by 
an  incisura  may  be  broadly  considered  an  hour-glass,  but  unless 
the  constriction  is  quite  deep  the  term  hour-glass  is  not  usually 
applied.  In  many  instances,  however,  the  local  contraction  is 
extreme,  the  typical  character  of  an  incisura  is  lost,  and  the 
hour-glass  form  is  dominant  (Fig.  194).  The  spasmodic  hour- 
glass of  gastric  ulcer  is  characterized  by  a  relatively  short  canal 
joining  the  two  chambers,  the  canal  being  usually  near  the  lesser 
curvature,  thus  giving  the  stomach  a  B-shape.  Spasmodic 
hour-glass  due  purely  to  reflex  spasm  arising  from  sources  out- 
side the  stomach  may  exactly  simulate  the  hour-glass  of  ulcer. 
Therefore,  the  usual  tests  should  be  applied  to  exclude  extrinsic 
spasm.  It  must  be  remembered  that  the  spastic  hour-glass  of 
ulcer  disappears  under  general  anesthesia,  and  consequently 
will  not  be  found  by  the  surgeon. 

Other  Forms  of  Spasm. — Besides  the  localized  incisura  or 
spastic  hour-glass,  gastric  ulcer  may  also  give  rise  to  more  ex- 
tensive spasm.  Regardless  of  the  situation  of  the  ulcer,  this 
diffuse  spasm  usually  affects  the  pyloric  portion  of  the  stomach, 
and  the  entire  pars  pylorica  may  be  involved  (Fig.  195).  On 
the  screen  and  plate  this  area  is  vaguely  shadowed,  resembling 
the  filling-defect  produced  by  a  prepyloric  cancer.  The  spastic 
distortion  is  constant,  and  cannot  be  effaced  by  massage.  Since 
similar  spasms  may  be  set  up  by  conditions  outside  the  stomach, 
these  must  be  excluded  if  possible. 

Differentiation.- — Given  any  of  the  foregoing  varieties  of 
spasm,  the  examiner's  first  task  is  to  determine  whether  they 
arise  from  lesions  within  or  without  the  stomach.     Differential 


262 


GASTRIC    ULCER 


Fig.  194. — Hour-glass  stomach.     Hour-glass  constriction  at  o. 


Fig.  195. — Two  ulcers  shown  at  a      Note  prepyloric  spasm  b. 


ORGANIC    HOUR-GLASS  263 

characters  have  been  discussed  at  some  length  in  the  chapter 
on  ''Gastrospasm."  Exchision  of  extrinsic  spasm  by  giving 
belladonna  and  reexamining  is  most  important.  An  incisura, 
hour-glass  or  diffuse  gastrospasm  which  is  not  relaxed^by  this 
drug,  usually  means  a  lesion  of  the  stomach,  most  often  an  ulcer. 
Among  the  exceptions,  which  are  not  numerous  or  freciuent,  are 
these : 


Fig.  196. — Gastric  ulcer  with  organic  hour-glass  stomach.  Ulcer  and  constriction 
at  a.  The  lower  loculus  of  the  hour-glass  is  only  partly  filled,  and  the  canal  joining  the 
two  loculi  is  short,  although  the  thin  stream  of  barium  trickling  down  the  lesser  curva- 
ture gives  the  impression  of  a  long  canal. 

1.  Duodenal  ulcer  occasionally  gives  rise  to  a  gastric  incisura 
or  hour-glass  which  resists  belladonna.  In  any  doubtful  case, 
therefore,  a  routine  examination  should  be  made  for  duodenal 
ulcer,  in  order  to  confirm  or  exclude  its  presence. 

2.  Exceptionally  a  small  gastric  cancer  may  have  an  incisura 
as  its  sole  indication.  Such  instances  are  so  rare  that  the  ex- 
aminer is  justified  in  his  usual  diagnosis  of  ulcer. 

Organic  Hour-glass. — Organic  hour-glass  stomach  is  an 
occasional  sequence  of  penetrating  or  perforating  gastric  ulcer. 


264  GASTRIC    ULCER 

The  constricted  portion  is  infiltrated  or  involved  in  adhesions, 
and  is  present  at  operation.  Roentgenologically  it  cannot  be 
differentiated  from  the  spastic  type  of  hour-glass  resulting  from 
ulcer  but  should  be  subjected  to  the  same  tests  as  the  latter. 
Like  the  spastic  form  it  is  usually  of  the  B-shape,  with  a  short 
canal  near  the  lesser  curvature  (Fig.  196).  This  serves  gener- 
ally to  distinguish  it  from  the  cancer  hour-glass,  which  is  more 
often  of  an  X-shape,  with  a  long  canal,  centrally  placed. 

Residue. — A  distinct  residue  in  the  stomach  from  the  six- 
hour  meal,  amounting  to  an  eighth  or  more  of  the  quantity 
taken,  is  a  relatively  common  accompaniment  of  gastric  ulcer. 
In  a  series  of  215  consecutive  cases,  we  noted  a  retention  in  118 
or  55  per  cent.  Thus  gastric  ulcer  stands  a  close  second  to  gas- 
tric cancer  in  this  respect. 

The  manner  in  which  an  ulcer  causes  a  gastric  retention  is 
not  definitely  known.  An  ulcer  immediately  in  the  pyloric  ring, 
which  is  relatively  uncommon,  may  cause  a  narrowing  of  the 
ring  either  by  localized  spasm  or  by  scar-contraction.  But  by 
far  the  greater  number  of  ulcers  are  situated  at  variable  dis- 
tances from  the  pylorus.  The  retentions  which  they  produce 
have  been  assigned  respectively  to  pylorospasm  excited  by  the 
ulcer  or  by  an  accornpanying  hyperacidity,  to  impairment  of 
peristalsis  and  to  the  hypotonus  which  is  often  associated  with 
ulcer.  An  extreme  type  of  organic  hour-glass  due  to  ulcer  may 
cause  a  retention  in  the  upper  loculus. 

A  residue  in  the  stomach  resulting  from  an  ulcer  is  some- 
times the  only  definite  evidence  which  the  examiner  can  discover. 
However,  a  retention  alone  is  not  sufficient  for  the  diagnosis  of 
ulcer,  since  various  causes  may  operate  to  produce  a  six-hour 
residue.  These  have  been  discussed  in  the  chapter  on  ''Ab- 
normal Stomach." 

Gastric  Hypotonus. — An  evident  loss  of  tone,  as  shown  by 
sagging  and  expansion  of  the  lower  gastric  pole  is  a  frequent 
accompaniment  of  ulcer,  not  only  of  ulcers  causing  obstruc- 
tion (Fig.  197)  but  occasionally  also  of  ulcers  situated  rather 
high   in   the    stomach    (Fig.    198).     Taken    alone,   hypotonus 


GASTRIC    HYPOTONUS 


265 


Fig.   197. — Gastric  ulcer,  immediately  prepj'loric  at  a.     Stomach  large  and  hypotonic. 


Fig.   198. — Large  hypotonic  stomach.     One-half  the  motor  meal  present  at  the  end  of 
six  hours.     No  organic  obstruction  at  pylorus.     Gastric  ulcer  at  a. 


266 


GASTRIC    ULCER 


possesses  little  significance,  for  it  is  an  expected  finding  in  the 
numerous  patients  with  enteroptotic  build.  However,  if  the 
hypotonus  does  not  accord  with  the  habitus  of  the  patient  the 
possibility  of  an  ulcer  should  be  thought  of.  In  conjunction 
with  other  secondary  signs,  hypotonus  has  a  contributory  value, 
depending  on  the  circumstances. 

The  Acute  Fish-hook. — An  acutely  flexed,  fish-hook  form 
of  the  stomach,  with  displacement  to  the  left  and  downward. 


Fig.  199. — ^Acute  fish-hook  form  of  stomach.     Ulcer  at  a. 


noted  by  the  older  observers  as  a  minor  roentgenologic  sign  of 
ulcer,  has  perhaps  received  more  prominence  than  it  merits 
(Fig.  199).  It  may  occur  with  or  without  an  ulcer.  The  snail- 
form  of  Haudek,  an  extreme  degree  of  flexion  due  to  scar-con- 
traction on  the  lesser  curvature,  is  of  some  importance,  but  cor- 
roboration by  other  signs  is  necessary  for  a  positive  diagnosis. 

Abnormalities  of  Peristalsis. — The  variations  of  peristalsis 
met  with  in  gastric  ulcer  include  weak  peristalsis,  hyperperistal- 


LESSENED    MOBILITY  267 

sis,  especially  of  irregular  type,  absence  of  peristalsis  from  the 
ulcer-bearing  area  and  antiperistalsis.  None  of  these  is  peculiar 
to  ulcer  but  all  of  them  are  more  or  less  suggestive  of  a  gastric 
lesion. 

Gastric  hypotonus  is  a  common  accompaniment  of  gastric 
ulcer,  and  hypotonus  is  usually  associated  with  sluggish  peristal- 
sis. An  ulcer  at  the  pylorus,  producing  obstruction,  may  give 
rise  to  vigorous  irregular  peristalsis,  if  loss  of  tone  has  not  fol- 
lowed.    Pyloric  ulcers,  however,  are  relatively  infrequent. 

All  organic  lesions  of  the  gastric  wall  tend  to  interfere  with 
peristaltic  movement  in  the  area  involved.  If  an  ulcer  is  situ- 
ated in  that  portion  of  the  stomach  where  peristaltic  waves  are 
commonly  visible,  there  may  be  a  noticeable  local  absence  of  the 
wave-depression,  especially  if  infiltration  about  the  ulcer  is 
extensive. 

Antiperistalsis  is  occasionally  noted  with  gastric  ulcer,  most 
often  when  six-hour  retention  is  also  present.  While  not  nec- 
essarily indicative  of  ulcer,  antiperistalsis  generally  denotes  the 
existence  of  organic  disease  either  in  the  stomach  or  near  beyond. 

Tender  Point. — A  sharply  localized  pressure-tender  point 
over  a  niche  is  of  confirmatory  value.  If  limited  to  an  area  on 
the  curvature  opposite  an  incisura,  but  without  the  existence  of 
a  niche  or  accessory  pocket,  suspicion  of  an  ulcer  is  increased, 
nevertheless  a  diagnostic  opinion  should  be  guarded.  To  be  of 
any  value,  a  pressure-tender  point  must  be  narrowly  circum- 
scribed, as  most  persons  have  more  or  less  tenderness  in  the 
epigastrium. 

Lessened  Mobility. — A  local  fixation  of  the  gastric  wall  often 
results  from  perforating  ulcer  with  the  production  of  adhesions. 
However,  fixation  may  ensue  from  any  perigastric  inflammation. 
Besides,  satisfactory  determination  of  the  actual  mobility  of  the 
stomach  depends  considerably  upon  its  form,  tone  and  position 
and  the  relaxation  of  the  abdominal  wall.  Unless  the  observer 
can  satisfy  himself  that  definite  fixation  is  present  at  a  certain 
point,  he  should  not  be  unduly  influenced  by  what  seems  to  be  a 
lessened  mobility  of  the  stomach  as  a  whole. 


268  GASTRIC   ULCER 

Value  of  Sign-groups. — In  this  analysis  we  have  endeavored 
to  emphasize  the  niche  and  the  accessory  pocket  as  being  the 
only  conclusive  roentgen  signs  of  ulcer.  The  exact  worth  of  the 
contributor^'  signs  enumerated  cannot,  of  course,  be  stated 
precisely,  yet  in  various  combinations  they  may  sustain  a  quah- 
fied  diagnosis  of  ulcer.  Chief  among  the  secondary  manifesta- 
tions are  the  six-hour  residue  and  the  spastic  phenomena — 
incism'a,  hour-glass  and  diffuse  spasm.  When  any  form  of  gas- 
trospasm  persists  after  belladonna  has  been  given  to  physiologic 
effect,  the  existence  of  an  intrinsic  lesion  is  faMy  pro^^ed,  and 
most  often  the  lesion  is  an  ulcer.  If  a  six-hour  retention  is  in- 
cluded in  the  complex,  it  is  strongly  corroborative.  Antiperis- 
talsis  is  also  generally  indicative  of  serious  pathology.  TMien 
only  secondary  signs  are  found,  the  conservative  roentgenologist 
win  be  content  with  the  opinion  that  a  lesion  is  present.  By  ex- 
cluding duodenal  ulcer  and  gastric  cancer  when  possible,  and  by 
correlating  the  roentgen  e^'idence  with  the  chnical  and  labora- 
tory findings  the  diagnosis  can  often  be  made  more  specific. 

Association  of  Gastric  with  Duodenal  Ulcer. — In  an  extensive 
series  of  gastric  ulcers  which  came  under  our  observation,  15  per 
cent,  were  associated  with  duodenal  ulcer.  This  frequency  of 
double  lesions  suggests  that  the  roentgenologist  should  not  be 
satisfied  simply  with  finding  a  gastric  ulcer,  but  should  always 
carrj^  his  investigation  to  the  duodenum  (see  Fig.  215). 

Carcinomatous  Ulcer. — The  roentgenologic  signs  of  ulcer 
differ  so  much  from  those  of  carcinoma  in  the  vast  majority  of 
cases  that  differentiation  requires  no  effort.  For  example,  a 
penetrating  ulcer  with  niche  and  incisura,  or  a  perforating  ulcer 
with  pocket  formation  bears  no  roentgenologic  resemblance  what- 
ever to  a  well-developed  cancer,  and  patients  with  only  such 
cancers  are  hkely  to  come  for  roentgen  examination.  In  a  gen- 
eral way,  ulcers  project  as  an  addition  to  the  gastric  ca^dty,  while 
cancers  encroach  on  the  gastric  lumen.  Between  the  t^T^ical 
ulcer  and  the  t^T)ical  cancer,  however,  there  is  a  smaU  percentage 
of  cases  in  which  roentgenologic  differentiation  is  difficult  or 
impossible. 


CARCINOMATOUS    ULCER 


269 


An  example  of  this  class  is  the  ulcer  which  on  microscopic 
study  shows  cancer-cells.  Here,  the  roentgen  signs  are  those  of 
ulcer,  and  no  other  diagnosis  can  usually  be  offered.  At  opera- 
tion the  lesion  is  macroscopically  an  ulcer,  and  only  microscopic 
examination  can  give  final  judgment.  Extreme  size  of  an 
ulcer-crater,  as  shown  by  a  very  large  niche,  should  make  one 
suspicious  of  malignancy,  a  fact  which  has  been  impressed  upon 
us  by  experience.  An  ulcer  with  a  niche  3  cm.  or  more  in 
diameter  is  likely  to  prove  cancerous  (Fig.  200). 


Fig.  200. — ^Large  gastric  ulcer  at  a;  found,  to  be  carcinomatous  at  operation. 


In  the  pyloric  region,  differentiation  of  ulcer  from  cancer  is 
often  troublesome.  The  only  roentgenologic  signs  may  be  a 
six-hour  rest  and  an  atypical  irregularity  of  contour,  and  the 
examiner  can  only  say  with  certainty  that  a  lesion  exists. 

A  small  cancer  may  have  an  incisura  as  its  sole  index,  and  the 
observer  will  be  incUned  to  suspect  ulcer  rather  than  cancer,  but 
this  sort  of  mistake  will  rarely  occur  and  can  hardly  be  consid- 
ered a  grave  error. 


270 


GASTEIC    ULCER 


Fig.  201. — Case  115,292.     Niche  of  perforating  ulcer  at  a. 


Fig.  202. — Case  122,649.  Gastric  ulcer.  Very  small  niche  at  a.  Acute  fish-hook 
form  of  stomach.  As  will  be  seen  by  the  pathologist's  report,  the  crater  of  the  ulcer 
was  only  2  millimeters  broad.  Such  an  ulcer  in  an  unfavorable  situation  might  easily 
escape  observation. 


REPORT    OF    CASES  271 

Case  115,292,  male,  aged  46  years.  Trouble  with  stomach  for 
seven  weeks;  no  prior  history,  except  possibly  acid  regurgitation  after 
meals  during  past  few  years.  He  now  complains  of  gnawing  epigastric 
pain,  worse  an  hour  after  meals.  There  is  no  definite  food-ease, 
though  he  feels  better  immediately  after  meals,  which  he  attributes  to 
keeping  quiet.  Water  relieves  pain  for  a  few  minutes;  exercise  ag- 
gravates it.  Some  pain  at  night,  at  different  times.  Five  weeks  ago 
he  vomited  on  frequent  occasions  one  to  two  hours  after  meals.  No 
hiematemesis.  His  stools  have  been  continuously  black.  Weight 
loss,  10  pounds.  Marked  epigastric  tenderness.  Hemoglobin  45. 
Total  acidity  64;  free  52;  combined  12.  Roentgen  findings:  Reten- 
tion of  one-fourth  the  motor  meal.  Niche  on  lesser  curvature,  just 
above  incisura  angularis  (Fig.  201).  Diagnosis:  Gastric  ulcer.  Find- 
ings at  operation:  Ulcer  of  lesser  curvature,  perforating  posteriorly 
against  pancreas,  and  adherent  to  it.     Gastro-enterostomy. 

Case  122,649,  female,  aged  40  years.  Trouble  with  stomach  for 
fifteen  years.  The  complaint  is  of  two  kinds:  first,  much  nausea 
without  vomiting.  The  nausea  is  worse  before  breakfast  and  is  eased 
by  taking  food  or  water.  Second,  for  six  years  occasional  attacks  of 
epigastric  pain,  radiating  to  the  right  costal  margin  and  to  the  back. 
The  pain  comes  a  half  hour  after  meals  and  lasts  to  the  next  meal,  or 
is  relieved  a  half  hour  by  eating  between  meals.  Relief  also  by  lying 
down.  Never  night  pain  or  vomiting.  The  attacks  last  for  two  or 
three  weeks  with  free  intervals  of  two  to  three  months.  Gradual 
weight  loss  for  twelve  years.  Hemoglobin  78.  Total  gastric  acidity 
38;  free  26;  combined  12.  Roentgen  findings:  No  retention.  Small 
niche  on  lesser  curvature  (Fig.  202).  Diagnosis:  Gastric  ulcer.  Find- 
ings at  operation :  Small  ulcer  about  the  middle  of  lesser  curvature  of 
stomach.  Excision.  Posterior  gastro-enterostomy.  Pathologist's 
report:  Ulcer.     Crater  2  mm.  in  diameter. 

Case  87,913,  male,  aged  40  years.  Ten  year  history  of  trouble  with 
stomach,  at  first  only  three  or  four  times  a  year,  but  the  attacks  have 
increased  in  duration  and  frequency.  He  now  complains  chiefly  of 
epigastric  pain  and  vomiting.  The  pain  is  referred  to  the  right  epigas- 
trium, radiates  to  the  back,  and  comes  three  or  four  hours  after  meals. 
With  the  pain  there  is  vomiting  of  food  and  sour  fluid.  On  occasions 
he  has  noted  in  the  vomit,  food  taken  the  day  before.  After  appendec- 
tomy two  years  ago  he  had  no  symptoms  for  six  months.  Weight 
loss,  34  pounds  in  four  months.  Hemoglobin  68.  Total  acidity  42, 
all  combined;  food  remnants.  Roentgen  findings:  Large  stomach. 
Retention  of  three-fourths  the  motor  meal  (Fig.  203).  No  hour-glass 
contracture.     Accessory  pocket  just  outside  lesser  curvature   (Fig. 


272 


GASTRIC    ULCER 


Fig.  203. — Case  87,913.  Perforating  gastric  iilcer.  Small  six-hour  retention  in 
accessory  pocket  at  a;  with  fluid  and  gas  above  it,  Retention  of  practically  the  entire 
motor  meal  in  stomach,  b. 


Fig.  204.— Case  87,913. 


Filled  stomach,  showing  accessory  pocket  outside 
gastric  lumen,   a. 


REPORT    OF    CASES  273 

204).  Peristalsis  vigorous.  Duodenum  not  seen  during  period  of 
examination.  Diagnosis:  Perforating  gastric  ulcer.  (The  hyper- 
peristalsis  should  have  suggested  the  possibility  of  a  duodenal  ulcer 
to^the  examiner,  but  the  gastric  ulcer  being  evident,  no  further  exami- 
nation was  ^made.)  Findings  at  operation:  (1)  Ulcer  of  lesser  curva- 
ture of  stomach  perforating  onto  pancreas  and  transverse  colon.  (2) 
Large,  hard,  obstructing  ulcer  of  the  duodenum  just  below  pylorus. 
Anterior  gastro-enterostomy. 

Case  30,520,  female,  aged  30  years.     When  first  seen  in  the  Mayo 
Clinic  in  1909  she  had  had  attacks  of  pain  in  the  region  of  the  left  costal 


Fig.  205. — Case  30,520.     Incisura  well  up  on  greater  curvature  at  a. 

arch  for  two  years.  The  pain  was  severe,  came  several  times  daily 
and  lasted  ten  or  fifteen  minutes  each  time.  Occasionally  morphin 
was  required  for  relief.  She  returned  to  the  Clinic  in  January,  1913. 
Under  medical  treatment  she  had  been  well  until  the  autumn  of  1912. 
Since  then  she  had  had  daily  attacks  of  pain  at  the  left  costal  arch, 
radiating  to  the  back,  graduallj^  growing  worse,  and  again  requiring 
morphin.  No  vomiting,  belching  or  sour  eructations.  Weight  loss, 
18  pounds  in  four  months.  Total  acidity  54;  free  50;  combined  4; 
trace  of  altered  blood.  Roentgen  findings:  No  retention.  Incisura, 
greater  curvature,  vertical  portion  of  stomach.  This  was  persistent  at 
a  second  examination  after  giving  belladonna  (Fig.  205).     Diagnosis: 

18 


274 


GASTEIC    ULCER 


Fig.  206. — Case  127,214.     Organic  hour-glasfe  stomach  of  gastric  ulcer  at  a.     No 

"nischen  symptom." 


Fig.  207. — Case  107,257.     Multiple  gastric  ulcers.     Pyloric  cud  puckered  and  adherent 
to  lesser  curvature.     Snail  form  of  stomach.     Pylorus  at  a. 


EEPORT    OF    CASES  275 

Gastric  ulcer.  Findings  at  operation:  (1)  Ulcer  the  size  of  a  quarter, 
high  on  the  lesser  curvature  and  posterior  wall,  firmly  adherent  to 
pancreas.  (2)  Chronic  appendicitis.  Operation:  Excision  of  ulcer. 
Appendectomy.  Pathologist's  report:  (1)  Simple  gastric  ulcer.  (2) 
Chronic  catarrhal  appendicitis. 

Case  127,214,  female,  aged  37  years.  For  five  years  past,  about 
once  a  week,  she  has  had  attacks  of  pain  in  the  left  epigastrium  radiat- 
ing between  the  shoulders.  The  pain  is  fairly  severe  at  times,  especially 
with  change  of  weather.  It  seems  to  be  brought  on  by  eating  but  may 
come  at  any  time.  Five  months  ago  for  a  period  of  two  months,  she 
had  daily  attacks,  then  a  respite  until  three  weeks  ago,  since  when  the 
attacks  have  been  of  daily  occurrence.  She  belches  gas,  and  vomitS' 
bitter  fluid.  Deep  inhalation  causes  pain  at  the  left  costal  arch.  No 
weight  loss.  Hemoglobin  80.  Total  acidity  54;  free  40;  combined  14. 
Roentgen  findings:  No  retention.  Hour-glass  stomach.  Reray  after 
belladonna:  Hour-glass  stomach  still  present.  Tender  point  corre- 
sponding to  constricted  area  (Fig.  206).  Diagnosis:  Gastric  ulcer. 
Findings  at  operation :  Ulcer  on  lesser  curvature,  5  inches  above  py- 
lorus.    Band  producing  hour-glass  contraction.     Gastro-enterostomy. 

Case  107,257,  female,  aged  52  years.  For  twenty-five  years  she 
has  had  attacks  of  gnawing  epigastric  pain,  coming  a  half  hour  to  one 
hour  after  meals  and  continuing  for  several  days  or  a  week,  with  free 
intervals  of  four  to  six  weeks.  Nine  years  ago  she  vomited  a  cupful  of 
blood,  but  did  not  have  severe  pain  on  that  occasion.  During  the  past 
year  the  pain  has  been  more  frequent ;  sometimes  relieved  by  food  and 
sometimes  not.  For  six  months  past  she  has  had  spells  of  pain  at  11 
p.m.  Two  months  ago  she  again  vomited  a  cupful  of  blood.  Alto- 
gether she  has  vomited  rarely.  There  is  much  gas  and  occasional  sour 
eructations.  Appendix  removed  nine  years  ago.  Weight  loss  slight. 
Hemoglobin  80.  Total  acids  10;  all  combined.  Roentgen  findings: 
Retention  of  half  the  six-hour  meal.  Antrum  acutely  flexed  and  adher- 
ent to  lesser  curvature.  Diagnosis:  Lesion  of  stomach  (Fig.  207). 
Findings  at  operation :  Multiple  ulcers  causing  an  acute  fish-hook  form 
of  stomach,  with  puckering  of  the  lesser  curvature  and  pylorus. 
Operation:  Finney  plastic. 

Case  98,523,  female,  aged  37  years.  Starting  about  20  years  ago, 
for  nine  years,  from  September  on  through  each  winter,  the  patient 
had  attacks  of  hard,  griping,  epigastric  pain.  The  pain  came  an  hour 
after  each  meal  and  lasted  to  the  next  meal.  It  was  eased  by  food, 
soda,  rest  and  change  of  posture.  Thirteen  years  ago  the  attacks 
became  shorter  but  more  severe,  coming  several  times  a  year  and  last- 
ing two  or  three  weeks  with  intervals  of  entire  freedom  between.     The 


276 


GASTRIC    ULCER 


Fig.  208. — Case  98,523.     First  examination.     Large  hypotonic  stomach  with 

incisura  at  a. 


Fig.  209. — Case  98,523.     Second  examination.     Niche  at  a;  hour-glass 
constriction  at  6. 


REPORT    OF    CASES  277 

pain  has  not  been  accompanied  by  sour  eructations  or  vomiting. 
During  the  past  year  the  attacks  have  come  at  short  intervals,  and  on 
two  occasions  the  pain  was  so  severe  as  to  requii'e  niorphin.  Weight 
loss  slight.  Two  gastric  analyses :  (1)  Total  acidity  36;  free  30;  com- 
bined 6.  (2)  Total  acidity  64;  free  54:  combined  10.  Roentgen  find- 
ings: First  examination.  January  10.  1914:  Large  stomach  with 
retention  of  half  the  six-hour  meal.  Incisura,  greater  curvature. 
Second  examination,  after  belladonna:  Conditions  unchanged  (Fig. 
208).  Diagnosis:  Gastric  ulcer.  Exploration  was  advised  but  re- 
fused. The  patient  returned  October  22.  1915.  At  this  time  a  third 
examination  revealed  the  same  conditions  as  previously,  except  that  a 
small  niche  was  now  visible  on  the  lesser  ciuwature  'Fig.  209j .  Find- 
ings at  operation:  (1)  Ulcer  very  high  on  lesser  ciu'vatm'e,  with 
semblance  of  hom"-glass.  (2)  Stones  in  gall-bladder.  Cautery  exci- 
sion of  ulcer;  gastro-enterostomy.  Cholecystectomy-.  Pathologist's 
report:  Chronic  catarrhal  cholecystitis;  cholelithiasis. 

Case  94,543,  female,  aged  28  years.  For  six  years  attacks  of  pain 
in  the  left  epigastrium  coming  two  or  thi'ee  hours  after  meals  and 
accompanied  by  vomiting  and  lasting  from  one  to  four  weeks.  She 
vomited  blood  six  years  ago  and  again  three  years  ago.  Pvecently  she 
was  in  bed  for  several  days  with  incessant  vomiting.  The  pain  radiates 
to  the  left  shoulder  and  at  times  requires  codeine  for  relief.  IN'o  defi- 
nite food-ease,  but  she  states  that  she  has  less  pain  immediately  after 
meals.  Little  loss  of  weight.  Hemoglobin  70.  Total  acidity  60; 
free  52;  combined  8;  food  remnants  definite.  Roentgen  findings: 
Large  stomach  with  retention  of  thi'ee-fourths  of  the  motor  meal. 
Niche  on  lesser  curvature  seen  on  oblique  xievr  only  (Fig.  210j. 
Incisura  opposite  on  greater  cui vatui e.  of  irregular  type.  Diagnosis : 
Gastric  ulcer.  Figs.  211,  212,  213,  214.  Findings  at  operation:  (1) 
L'lcer  on  the  lesser  ctu'vature  at  incism'a  ang-ularis,  and  a  contact  ulcer 
on  the  posterior  wall,  causing  hour-glass  stomach.  Fleer  very  adher- 
ent to  liver  and  pancreas.  (2)  LTcer  of  duodenmn,  anterior  wall, 
moderately  obstructive.  Operation:  ilj  Sleeve-resection  of  stomach. 
(2)  Excision  duodenal  ulcer;  Finney  pyloroplastj'.  Pathologi5t's  re- 
port: Multiple  simple  ulcers  of  stomach  (Fig.  214).  Post-operative 
roentgen  finchngs:  Five  weeks  after  operation:  Very  small  stomach  with 
contraction  on  greater  cinvatm'e  at  site  of  sleeve  resection  (Fig.  212) . 
Four  and  one-half  months  after  operation:  Stomach  shows  marked 
increase  in  size  (Fig.  213).  One  year  after  operation:  Retention  of 
one-fourth  the  motor  meal.  Contracture  still  present  at  site  of  resec- 
tion.    Stomach  still  larger  in  size. 

Case  150,820,  female,  aged  66  years.     Intermittent  gastric  dis- 


278 


GASTRIC    ULCER 


Fig.  210. — Case  94,543.     Oblique  view.     Niche,  a,  on  lesser  curvature. 

ineisura  at  b. 


Wavy 


Fig.   211. — Case  94,54.3.      Dorso-ventral    view.        Suggestion  of  a  double  ineisura  on 
greater  curvature.      No  niche  seen  on  lesser  curvature. 


REPORT    or    CASES 


279 


Fig.  212. — Case  94,543.     Stomach  soon  after  sleeve-resection.     Note  small  size  of 
stomach  and  the  contraction,  a,  at  suture-line. 


Fig.  213. — Case  94, .543.     Stomach  approximating  normal  capacity  a  few  months  after 
operation.     Contraction,  a,  at  suture-line  still  present. 


280  GASTRIC    ULCER 

turbances  for  the  past  12  years;  food  distress  rather  than  food-ease; 
epigastric  soreness,  more  marked  on  the  left  side.  Patient  says  she  is 
nauseated  most  of  the  time  and  vomits  often  without  effort  or  rehef. 
For  years  unable  to  lie  on  left  side,  because  of  nausea.  No  bleeding. 
Always  light  eater;  lived  on  pint  of  milk  and  cream  daily  for  years.  In 
the  past  six  months  she  has  been  progressively  worse.  Soreness  left 
side,  no  desire  for  food,  because  of  nausea  and  vomiting.  Weight 
early  125  pounds,  two  years  ago  103  pounds,  now  99  pounds.  Total 
acidity  34,  free  HCl  28;  combined  6.  Hemoglobin  88  per  cent.;  reds 
4,624,000.     Roentgen  findings:  Stomach  large,  with  a  number  two 


Fig.    214. — Case    94,543.     Photograph  of  resected  specimen,  showing  multiple  ulcers 
and  puckered  areas  of  healed  ulcers. 

retention  at  the  end  of  six  hours.  Small  six-hour  retention  in  the 
duodenum.  Peristalsis  vigorous  and  of  irregular  type.  Niche,  pre- 
pyloric, lesser  curvature.  Cap  deformity  (Fig.  215).  Diagnosis: 
Gastric  ulcer;  duodenal  ulcer.  Operative  findings:  Double  ulcer: 
Ulcer  of  the  stomach  3  inches  above  the  pylorus  on  lesser  curvature. 
Ulcer  duodenum  extending  up  to  pjdoric  ring.  Operation:  1.  Cau- 
tery excision  gastric  ulcer.  2.  Pylorus  blocked  by  two  silk  mattress 
sutures.     3.  Posterior  gastro-enterostomj^ 

Case  135,028,  male,  aged  37  j^ears.  Trouble  with  stomach  one 
year,  almost  continuous,  never  well  more  than  two  or  three  days  in 
succession.  Burning  epigastric  pain,  two  to  three  hours  after  meals, 
and  at  10  p.m.  Relief  by  soda;  partial  food  relief.  Belching  and 
water-brash.     Vomited  once,  ten  months  ago;  some  blood.     No  vomit- 


REPORT    OF    CASES 


281 


ing  since.  Feels  best  with  stomach  entirely  empty.  Some  loss  of 
weight.  Hemoglobin  90.  Two  gastric  analyses:  (1)  Total  acidity 
32;  free  24;  combined  8.  (2)  Total  acidity  50;  free  36;  combined  14. 
Roentgen  findings:  Screen  and  plate  examination  negative  (Fig.  216). 
Findings  at  operation :  Ulcer  on  lesser  cm'vature  of  the  stomach,  high 
up  near  cardiac  end.  Operation:  Cauterization  of  ulcer.  Posterior 
gastro-enterostomy. 

Case  139,094,  female,  aged  47  years.  For  twenty  years  she  has  had 
attacks  of  "heartburn"  with  some  pain  in  the  stomach  about  three 
times  a  week.     This  has  been  getting  more  frequent  and  now  occurs 


Fig.  215. — Case  150,820.  Niche  of  gastric  ulcer  at  a.  Spastic  deformity  of 
duodenal  bulb  at  b,  constant  at  screen-examination  and  on  all  plates.  The  spasm 
was  intrinsic  and  due  to  duodenal  ulcer. 


about  one  hour  after  each  meal.  Acids  and  baked  potatoes  cause  most 
discomfort;  milk  and  crackers  least.  The  attacks  last  several  hours; 
relief  by  soda.  She  is  free  from  distress  in  the  intervals.  There  is 
much  gas,  bloating  and  belching,  and  frequent  sour  eructations,  but 
never  vomiting.  Normal  weight  100;  present  76.  Hemoglobin  35. 
Firm  mass,  dull  to  percussion  1  inch  to  right  of  mid-line,  extending 
from  costal  margin  to  1  inch  below  the  level  of  the  umbilicus  and  4 
inches  to  the  left  of  mid-line.  Total  acidity  46;  free  30;  combined  16; 
altered  blood.    Wassermann  negative.    Roentgen  findings :  Retention 


282 


GASTRIC    ULCER 


Fig.  216. — Case  135,028.     Gastric  ulcer,  lesser  curvature,  high  up  in  cardia. 
Screen  and  plate  findings  negative.     Plates  made  with  patient  prone.J 


Fig.   217. — Case  139,094.     Large  perforating  ulcer  at  a.     Hour-glass  contracture  at  6. 


REPORT    OF    CASES  283 

of  three-fourths  of  the  six-hour  meal.  Hour-glass  stomach.  Large 
perforating  ulcer,  on  the  lesser  curvature,  of  the  mid-portion  of  stom- 
ach (Fig.  217).  Patient  died  one  week  after  the  examination.  Post- 
mortem findings :  The  stomach  is  filled  with  a  fibrinous  clot.  There  is 
a  carcinoma  which  has  developed  on  a  large  saddle  ulcer  which  has 
perforated  against  the  pancreas.  At  one  point  in  the  base  of  the  ulcer, 
the  origin  of  the  hemorrhage,  which  occurred  from  an  artery  in  the 
pancreas,  can  be  seen.  The  edges  of  the  carcinomatous  ulcer  are 
thickened  and  calloused. 


Fig.  218. — Case  151, 968,     Niche  higli  on  lesser  curvature  at  a. 

Case  151,968,  male,  aged  59  years.  Gastric  trouble  for  the  last 
five  or  six  years.  Present  trouble  began  six  months  ago,  and  has  been 
more  or  less  continuous.  Gastric  symptoms  consist  of  dull  epigastric 
pain  coming  on  soon  after  meals  with  soda-ease.  Much  gas,  sour 
eructations,  occasional  heartburn  and  water-brash.  Vomiting  is  a 
prominent  feature  since  onset,  coming  on  from  one-half  to  three 
hours  after  meals.  Never  has  been  any  food-ease,  patient  always 
feeling  better  when  stomach  is  empty.  Usual  weight  155  pounds, 
now  139  pounds.  Hemoglobin  85  per  cent.;  reds  5,200,000.  Total 
acidity  26;  free  HCl  0;  combined  26.  Wassermann  negative.  Roent- 
gen findings:  Large  stomach  with  retention  of  three-fourths  of  the 


284 


GASTRIC    ULCER 


Fig.  219. 


Fig.  220. 


Fig.  222. 


Fig.  221. 


Figs.  219,  220,  221,  222. — Gastric  ulcers  with  niches  of  various  sizes  and  situations. 
The  niche  is  shown  at  a. 


ULCER-NICHES 


285 


Fig.  223. 


Fig-  225. 


Fig.  224. 


\-^^' 


1^12 


r 


Fig.  226. 


Figs.  223,  224,  225,  226. — Gastric  ulcers  with  niches  of  various  sizes  and  situations. 
The  niche  is  shown  at  a. 


286 


GASTRIC    ULCER 


Fig.  227. 


Fig.   228. 


Fig.  229. 


Fig.  230. 


Figs.  227,  228,  229,  2.30. — Perforating  gastric  ulcers  with  accessory  pockets,  with  and 
without  hour-glass  contracture.     Accessory  pocket,  a.     Hour-glass  constriction,  b. 


ORGANIC    HOUR-GLASS 


287 


Fig.  231. 


Fig.  232. 


Fig.  233 


Fig.  234. 


Figs.  231,  232,  233,  234. — Gastric  ulcers  producing  organic  hour-glass  contracture,  b. 

No  visible  niche. 


288 


GASTRIC   ULCER 


Fig.  236. 


Fig.  235. 


Fig.  237. 


Fig.  238. 


Fig.  235. — No  niche,  no  evidence  of  any  indurated  area.  Barium  excluded  from 
prepyloric  region  at  a.  There  was  also  a  retention  of  one-fourth  the  motor  meal.  At 
operation 'a^  small  slit-like  ulcer  was  found  on  the  lesser  curvature,  body  of  stomach. 
See  Fig.  236. 

FiG.l236. — Photograph  of  specimen  from  case  shown  in  Fig.  235.  The  minuteness 
and^shallowness  of  the  ulcer  explain  the  absence  of  a  visible  niche. 

Fig.  237. — Prepyloric  irregularity  at  a.  Diagnosis:  Prepyloric  lesion.  At  opera- 
tion, gastric  ulcer,  just  above  pylorus,  posterior  wall. 

Fig.  238. — Large  shallow  niche  of  a  saddle  ulcer  at  a.  Such  a  niche  might  easily 
be  mistaken  for  the  bulge  between  two  peristaltic  waves. 


REPORT    OF    CASES 


289 


lolfGf 


Fig.  240. — Photograph  of  specimen 
showing  cavity  of  ulcer. 


Fig.  239. — Accessory  pocket  of  per- 
forating ulcer  at  a.  Oblique  view. 
Perforation  against  pancreas.  See  speci- 
men, Fig.  240, 


Fig.  241. — Gastric  ulcer  near  pylorus,  Fig.  242. — Photograph     ofi     section 

producing  irregularity   and  obstruction  at  from  stomach  showing  crater  of  penetra- 

a.     Shadow  of  gallstone  at  b.     Barium  in  ting  ulcer  at  c, 
duodenum,  c. 


19 


290 


GASTRIC   ULCER 


Fig.  244.- 
sected    from 
ulcer  at  c. 


-Photograph  of  ulcer  re- 
stomach.       Crater    of 


Fig.  243. — Gastric  ulcer.  Niche  at  a. 
Incisura  at  b  Resected  specimen  shown 
in  Fig.  244. 


Fig.  245. — Photomicrograph, 
4x,  of  cross  section  through  an 
ulcer.  The  destruction  extends 
to  the  musculature,  but  not  into 
it.  The  excavation,  c,  is  the 
niche  seen  in  the  roentgenogram. 
Fig.  243. 


Fig.  246  — Large  stomach  with  retention  of 
half  the  six-hour  meal.  Prepyloric  narrowing  at 
a.  Diagnosis:  Obstructive  lesion  on  gastric  side  of 
pyloric  ring.  At  operation :  Fairly  large  ulcer  high 
on  lesser  curvature.  (The  diagnosis  was  based 
wholly  on  the  secondary  signs  The  prepyloric 
narrowing  was  due  to  spasm). 


REFERENCES  291 

motor  meal.  Small  niche  high  on  the  lesser  curvature.  Peristalsis  of 
vigorous  irregular  type.  Practically  no  barium  seen  passing  from 
stomach  into  the  duodenum.  Diagnosis  gastric  ulcer;  obstruction  just 
beyond  pylorus  (Fig.  218).  Operative  findings:  Small  ulcer  high  on 
the  lesser  curvature.  Ulcer  duodenum  producing  obstruction.  Duode- 
num was  completely  sealed  against  the  gall-bladder.  Empyema  of 
the  gall-bladder  which  was  filled  with  stones.  Gall-bladder  had  per- 
forated into  duodenum,  producing  a  fistulous  tract  between.  Opera- 
tion: (1)  Cautery  excision,  ulcer  of  stomach.  (2)  Posterior  gastro- 
enterostomy. (3)  Cholecystectomy.  (4)  Closure  of  fistulous  tract 
between  gall-bladder  and  duodenum.  Pathologist's  report:  Gall- 
bladder with  stones,  chronic  cholecystitis. 

REFERENCES 

1.  Hemmeter,  J.  C:  "Neue  Methoden  zur  Diagnose  der  Magenge- 

schwiirs."     Arch.filr  Verdauungshranhheiten,  1906,  xii,  357-364. 

2.  Wilson",  L.  B.  and  McDowell,  I.  W.:  "A  Further  Report  of  the 

Pathologic  Evidence  of  the  Relationship  of  Gastric  Ulcer  and 
Gastric  Carcinoma."  Amer.  Jour.  Med.  Sci.,  1914,  cxlviii,  796- 
816. 

3.  Reiche,  F.:  "Zur  Diagnose  des  Ulcus  Ventriculi  im  Rontgenbild." 

Fortschritte  a.d.  Geh.  der-  Rontgenstrahlen,  1909,  xiv,  17.1-173. 

4.  Haudek,   M.:  ''Die    Rontgendiagnose  cles   kallosen  (penetrieren- 

den)  Magengeschwiire  und  ihre  Bedeutung."  Munch.  Med. 
Wchnschr.,  1910,  Ivii,  2463-2466. 


CHAPTER  XrV 

MISCELLANEOUS  GASTRIC  CONDITIONS 

Hair-ball   and    Other   Foreign   Bodies — Diverticula — Diaphragmatic 
Hernia  and  Elevation  of  the  Diaphragm — Gastroptosis 

HAIR-BALL 

Unique  among  the  foreign  bodies  which  are  occasionally 
found  in  the  stomach,  the  hair-ball  (trichobezoar)  possesses 
almost  theatrical  interest. 

Butterworth^  was  able  to  collect  42  cases  from  the  literature 
including  1  of  his  own.  He  gives  an  extensive  bibliography. 
Moore-  has  found  11  additional  published  reports,  to  which  he 
gives  references,  and  adds  1  himself. 

Burchard^  reviews  some  of  the  cases  that  were  examined 
by  the  roentgen-ray,  including  Franke's'^  and  Schwarz's.'^  In 
Franke's  case  there  was  a  hard,  smooth,  painless  tumor  in  the 
region  of  the  stomach.  In  the  roentgen  picture  there  was  an 
irregularly  mottled  shadow  ending  in  an  arch  above.  The  diag- 
nosis of  trichobezoar  was  made  on  the  combination  of  the  cUnical 
and  roentgen  findings  and  w^as  confirmed  at  operation.  Schwarz's 
case  showed  no  complete  bismuth  shadow  of  the  stomach,  but 
only  a  streak  along  the  greater  curvature. 

In  Kampmann's^  case  also,  that  of  a  ten-year-old  girl,  the 
mass  filled  the  stomach.  The  roentgen-ray  showed  uneven  dis- 
tribution of  the  bismuth  meal.  Xo  gas-bubble  was  present. 
Clairmont  and  Haudek^  describe  a  case  in  which  a  hair-ball  of 
moderate  size  could  be  displaced  into  the  upper  portion  of  the 
stomach  and  its  arched  shadow  could  be  seen  in  the  gas-bubble. 

Huttenbach^  gives  extensive  details  of  the  case  of  an  eighteen- 
year-old  woman.  At  the  roentgen  examination  of  the  stomach 
the   contrast   meal   showed  an  uneven   splotching.     The   gas- 

292 


HAIR-BALL 


293 


Fig.  247. — Holland's  case  of  hair-balls  in  the  stomach. 


Fig..  ^248. — Hair-ball  in  the  stomach  (Ramsbottom  and  Barclay).     The  projection  of  the 
hair-mass  into  the  gas-bubble  is  well  shown. 


294  MISCELLANEOUS    GASTRIC    COXDITIOXS 

bubble  could  not  be  seen.  At  operation  the  hair-ball  was  found 
to  form  a  complete  cast  of  the  gastric  cavity,  with  a  small  pro- 
jection into  the  duodenum.  It  was  quite  hard,  though  porous, 
and  covered  with  a  grayish-white  bacterial  growth. 

Holland's^  patient  was  a  young  woman,  aged  29.  The  upper 
abdomen  was  occupied  by  a  very  large  tumor  which  reached  to 
the  umbilicus.  When  examined  with  the  screen,  the  barium 
sulphate  mixture  rapidly  mapped  out  the  stomach  though 
somewhat  faintly,  but  showed  two  dark  transverse  bands. 
Later,  a  definite  history  of  hair-swallowing  was  obtained.  At 
operation  three  large  hair-balls  were  removed.  They  filled  the 
stomach  almost  completely.  The  pecuhar  roentgen  appearance 
was  evidently  due  to  the  barium  mixture  flowing  between  the 
wall  of  the  stomach  and  the  hair-balls,  and  to  a  certain  extent 
sticking  to  the  surfaces  of  the  latter,  while  the  dark  hands  were 
caused  by  the  opaque  meal  entering  the  joints  between  (Fig. 
247).  The  case  reported  by  Ramsbottom  and  Barclay ^°  was 
that  of  a  woman,  28,  who  gave  a  history  of  gastric  disturbance 
for  a  few  weeks  only.  In  the  left  abdomen  was  a  large,  but  not 
tender,  freely  movable  tumor,  which  was  at  first  believed  to  be 
the  spleen.  WTien  examined  roentgenoscopically  b}^  Barclay  the 
bismuth  meal  surrounded  the  mass  and  outhned  the  curvatures 
of  the  stomach.  By  palpation  the  tumor  could  be  shifted 
upward,  the  top  of  it  rising  above  the  bismuth  and  showing  a 
rounded  shadow  in  the  gas-bubble  (Fig.  248).  Barclay  gave  the 
opinion  that  the  mass  was  a  hair-ball.  Subsequently  it  was 
learned  that  twenty  years  previously  in  an  attack  of  scarlet 
fever  the  patient  had  eaten  practically  aU  of  her  hair.  At  opera- 
tion the  hair-baU  was  found  to  be  9  inches  long  by  3  inches  wide, 
with  a  process  extending  into  the  duodenum. 

For  obvious  reasons,  by  far  the  greater  number  of  hair-balls 
are  found  in  females,  and  more  often  under  the  age  of  20.  Three 
or  4  cases,  however,  have  been  reported  in  boys  and  men.  Neu- 
roses, dementia,  mania,  and  idiocy  play  a  part.  The  form  and 
size  of  the  hair-masses  vary.  Large  bezoars  usually  form  casts 
of  the  gastric  lumen;  the  smaller  ones  may  be  spherical  or  kidne}^- 


HAIR-BALL 


295 


shaped.     In  one  case  reported,  the  mass  weighed  more  than  4 
pounds. 

The  symptoms  of  the  condition  are  not  distinctive.  They 
include  loss  of  appetite,  pressure,  distress,  pain  and  vomiting. 
The  patients  usually  complain  most  after  eating  (Hiittenbach) . 
In  some  instances  small  hair-masses  have  been  discovered  in  the 


Fig.  249. — Case  148,917.     Photograph  of  hair-ball  after  removal  from  stomach,  show- 
ing a  mass  of  hair,  hay,  and  rags. 

stools,  and  in  one  case  they  were  ejected  by  vomiting.  The 
palpable  tumor  is  freely  movable,  and  has  been  variously  mis- 
taken for  a  splenic,  pancreatic  or  renal  growth,  or  a  fecal  ac- 
cumulation in  the  colon. 

In  most  of  the  cases  that  were  subjected  to  roentgen  examina- 
tion it  is  noteworthy  that  the  opaque  meal  penetrated  between 


296 


MISCELLANEOUS   GASTRIC   CONDITIONS 


the  wall  of  the  stomach  and  the  hair-mass,  thus  visualizing  a 
regular  gastric  contour,  but  the  area  occupied  by  the  hair-ball 
was  only  faintly  and  diffusely  shadowed.  When,  in  addition, 
the  tumor-mass  can  be  displaced  upward  into  the  gas-bubble^ 
the  evidence  of  a  foreign  body  is  complete.  Combination  of  the 
roentgenologic  and  clinical  findings  should  always  establish  the 
diagnosis.  During  the  past  two  years  2  cases  have  been  seen  in 
the  Mayo  Clinic.  Unfortunately,  neither  of  the  patients  was 
examined  by  the  roentgen-ray. 


Fig.  250.— Case  107,244.     Photograph  of  hair-ball. 

Case  148,917,  female,  aged  32  years.  The  patient  has  been  an 
inmate  of  the  State  Hospital  for  Insane  during  the  past  eighteen 
months,  and  on  previous  occasions  for  a  year  at  a  time  in  other  hos- 
pitals. She  complains  of  attacks  of  abdominal  pain,  coming  at  inter- 
vals of  one  to  six  months,  and  lasting  two  weeks.  The  pain  is  rather 
diffuse  but  worse  on  the  left  side  and  is  associated  with  nausea  and 
vomiting.  Hemoglobin  75.  Movable  mass,  Hke  a  floating  spleen,  in 
left  epigastrium.  Findings  at  operation:  Hair-ball  10  inches  long  in 
stomach,  was  removed  through  anterior  longitudinal  incision.  Patho- 
logical report:  Foreign  body.  Mass  composed  of  hair,  hay,  strings 
and  cloth.     Weight  240  gm.  (Fig.  249). 


FOREIGN   BODIES  297 

Case  107,244,  female,  aged  10  years.  Scarlet  fever  at  9  years  of 
age.  Well  until  ten  days  ago,  when  she  had  a  "bilious  attack,"  with 
headache,  cramping  abdominal  pain,  and  nausea;  sHght  fever.  She  is 
restless  at  night  and  pulls  and  chews  her  hair.  Hemoglobin  75. 
Large,  hard,  irregular,  freely  movable,  mass,  extending  obliquely  from 
left  costal  margin  to  right  abdomen.  The  mass  is  not  tender  and 
crepitates  on  palpation.  Findings  at  operation:  Large  hair -ball,  al- 
most filling  stomach.  Gastrotomy  and  removal  of  mass.  Patholo- 
gist's report:  Hair-ball.     Weight  2  pounds  (Fig.  250). 

OTHER  FOREIGN  BODIES 

The  foreign  bodies  which  are  swallow^ed  either  accidentally 
or  intentionally  are  most  often  metallic,  and  their  detection  in 
the  stomach  by  the  roentgen-ray  is  not  usually  difficult.  Occa- 
sionally, when  it  is  uncertain  whether  the  object  is  within  the 
stomach  or  has  passed  into  the  bowel,  the  opaque  meal  or  enema 
may  be  of  assistance.  If  the  shadow  of  the  foreign  material  is 
enveloped  in  that  of  the  meal  in  the  stomach,  at  all  angles  of 
view,  its  intragastric  location  msiy  be  assumed.  The  meal  may 
also  aid  in  finding  non-opaque  bodies. 

Case  141,504,  female,  aged  29  years.  Patient  at  the  Rochester 
State  Hospital  for  Insane,  in  good  physical  health  and  apparently 
suffering  no  distress.  By  chance,  the  nm'se  in  charge  saw  a  teaspoon 
disappear  into  the  woman's  mouth  and  she  was  brought  to  our  clinic. 
Roentgen  findings:  Spoons  in  stomach  nested  together.  Hair  pin 
(Fig.  251).  At  operation  seven  teaspoons  Ijdng  together  ''spoon 
fashion"  were  found,  together  with  a  hair  pin,  some  straw  and  small 
pieces  of  twigs.  Xo  injury  to  the  gastric  mucosa  was  discovered. 
The  spoons,  which  were  of  plated  metal,  were  not  eroded.  They  were 
each  6  inches  in  length  and  l}^  inches  across  the  bowl.  Recovery  was 
uneventful. 

Case  151,406,  infant,  ten  months  old.  The  youngster  pulled  off  its 
stocking,  removed  an  open  safety-pin  and  swallowed  it.  The  roent- 
genogram herewith  shows  the  open  safet3-pin  in  the  stomach  (Fig. 
252) .  The  case  is  remarkable  from  the  fact  that  the  pin,  though  open, 
passed  through  without  hindrance. 

DIVERTICULA 

Few  cases  of  gastric  diverticula  have  been  found  in  man. 
The  excavation  into  adjacent  tissues  sometimes  produced  by 


298 


MISCELLANEOUS   GASTRIC    CONDITIONS 


'^.yV'xx^, 


Fig.  251. — Case  141,504.     Nested  spoons  and  a  hairpin  in  stomach. 


Fig.  252. — Case  151,400.     Open  satety  pin  in  infant's  stomach. 


DIVERTICULA  299 

perforating  gastric  ulcer  is  not  really  a  diverticulum,  though 
often  thus  called.  Even  the  designation  ''false  diverticulum" 
is  hardly  applicable,  and  we  have  therefore  selected  the  term 
''accessory  pocket"  (see  "Gastric  Ulcer").  Pathologists  cus- 
tomarily divide  diverticula  into  the  "true"  and  "false."  In 
the  former  the  diverticular  sac  contains  all  the  coats  of  the  vis- 
cus-mucosa,  muscle  and  serosa;  in  the  false  type  one  or  more 


Fig.  253. — Case  90,125.     Diverticular  sac  at  d. 

layers  are  missing,  most  often  the  muscular,  in  which  case  the 
condition  has  been  described  as  "hernia  mucosae." 

Falconer^^  reports  a  congenital  diverticulum  of  the  stomach, 
found  at  autopsy.  It  arose  from  the  pyloric  canal  on  the  greater 
curvature  side,  was  j-i  inch  in  length  and  admitted  the  forefinger. 
In  C.  H.  Mayo's^^  case  the  diverticulum  was  on  the  anterior 
wall  of  the  stomach,  2  inches  from  the  pylorus.  It  was  l^i 
inches  in  length  and  contained  a  well- marked  carcinoma  in  its 
outer  portion. 

One  case  of  gastric  diverticulum  has  come  under  our  observa- 
tion: 


300  MISCELLANEOUS   GASTRIC    CONDITIONS 


Fig.  254. — Case  90,125.     Photograph  of  specimen.     Diverticulum  at  d;  ulcer  at  u. 


Fig.  255. — Case  90,125.     Outside  view  of  diverticular  sac,  d. 


DIAPHRAGMATIC    HERNIA  301 

Case  90,125,  male,  aged  54  years.  Twenty-year  history  of  stomach 
trouble.  Attacks  usuallj^  in  autumn,  lasting  some  weeks,  of  epigastric 
pain,  two  hours  after  meals,  relieved  by  vomiting.  Present  attack 
has  lasted  three  months,  the  pain  is  of  a  burning  character,  comes  two 
or  three  hours  after  meals,  and  is  relieved  by  vomiting.  Weight  loss, 
25  pounds.  Total  acidity  36,  all  free;  food  remnants.  Hemoglobin 
60.  Roentgen  findings:  Small  retention  from  the  six-hour  meal  in 
what  was  believed  to  be  the  duodenal  bulb.  Hyperperistalsis.  Bulb 
irregular.  Diagnosis:  Duodenal  ulcer  (Fig.  253).  Findings  at  opera- 
tion: Obstruction  at  the  pylorus  believed  to  be  due  to  a  duodenal 
ulcer.  Operation:  Gastro-enterostomy.  Findings  at  autopsy:  The 
specimen  taken  from  the  stomach,  post-mortem,  is  illustrated  in  Figs. 
254  and  255.  In  Fig.  254  two  depressions  are  seen  just  proximal  to 
the  pyloric  ring.  One  of  these  is  a  callous  ulcer,  the  other,  near  by,  is 
the  opening  of  a  diverticulum. 

DIAPHRAGMATIC     HERNIA    AND     ELEVATION    OF    THE    DIAPHRAGM 

(EVENTRATION) 

Diaphragmatic  hernia,  with  protrusion  of  the  stomach  or 
other  abdominal  viscera  into  the  thoracic  cavity,  and  a  related 
condition,  elevation  of  the  diaphragm,  though  not  common, 
are  of  some  practical  importance.  Both  may  give  rise  to  marked 
gastric  symptoms.  The  former  is  an  actual  rupture  of  the  dia- 
phragm. The  latter  is  not,  although  the  term  ''eventration," 
w^hich  is  frequently  used  as  a  synonym,  implies  a  rupture. 
While  either  may  affect  the  right  half  of  the  diaphragm,  nearly 
all  the  cases  reported  have  been  left-sided.  Elevation  is  usually, 
if  not  always,  congenital,  or  due  to  inborn  weaknesses.  It  is 
not  surgical.  Diaphragmatic  hernia  may  be  either  congenital 
or  acquired.  It  is  generally  surgical.  In  the  traumatic  form, 
the  history  of  a  crushing  injury  of  the  lower  thorax  and  upper 
abdomen,  or  a  sudden  doubling  of  the  body  with  the  knees 
against  the  chest,  can  often  be  obtained. 

The  clinical  symptoms  and  physical  signs  of  the  two  condi- 
tions are  not  essentially  different,  and  the  roentgen  examination 
affords  the  most  effective  means  of  exact  diagnosis  and  of  differ- 
entiating the  one  from  the  other.  Among  those  who  have 
written  concerning  the  roentgen  signs  may  be  mentioned  Giffin,^^ 


302 


MISCELLANEOUS   GASTRIC   CONDITIONS 


Becker/^  Sailer  and  Rhein/'^  Arnsperger,^'^  Kienbock,^^  Hilde- 
brand  and  Hess,^^  and  Koniger.^^ 

Examination  with  the  opaque  meal  is  preferable,  although 
much  can  be  determined  without  it,  or  by  inflating  the  stomach. 
With  the  patient  recumbent,  either  prone  or  supine,  the  eleva- 
tion or  herniation  is  more  accentuated  than  in  the  standing 
position. 

In  left-sided  elevation  of  the  diaphragm  (eventration)  the 
left  arch  of  the  diaphragm,  which  is  normally  lower  than  the 


Fig.   256.— Case  136,932.     Barium-iiUed  stomach  high  in  left  chest. 


right,  is  now  seen  to  be  markedly  higher  than  its  fellow,  and  its 
convexity  is  increased.  The  heart  is  either  raised  or  displaced 
to  the  right.  The  gas-bubble  (patient  standing)  is  forced  up- 
ward with  the  arch,  is  increased  in  size,  and  no  shadows  of  lung- 
tissue  are  seen  within  the  transparent  area  of  the  bubble.  Both 
arches  show  respiratory  movement,  though  the  excursions  may 
be  shorter.  On  filling  the  stomach  with  the  barium  meal,  its 
high-lying  position  becomes  evident. 


DIAPHRAGMATIC    HERNIA 


303 


Fig.  257. — Case  130,932.     Colon-ray  on  two  plates.     The  splenic  loop  extends  up  to 
the  second  left  intercostal  space. 


304 


MISCELLANEOUS   GASTEIC   CONDITIONS 


In  left-sided  diaphragmatic  hernia  the  roentgen  signs  are 
usually  more  exaggerated.  The  heart  is  displaced  to  the  right 
b}^  the  herniated  stomach.  Through  the  gas-bubble,  which  is 
usually!  increased  in  size,  lung-markings  may  be  seen.  The 
dome-shape  of  the  left  arch  is  lost,  if  the  arch  can  be  made  out 
at  all.  Especially  notable  is  the  "paradoxic  respiratory  phe- 
nomenon"; on  forced  inspiration  the  right  diaphragm  descends 
while  the  clear  area  in  the  left  chest  rises;  in  expiration  the 


Fig.  _'o>. —  Case  136,932.     Stomach  after  operation. 


reverse  occurs.  This  point  differentiates  hernia  from  elevation. 
By  giving  a  barium  meal  the  herniation  of  the  stomach  can  be 
established.  In  some  instances  the  colon  also  takes  part  in  the 
hernia,  and  this  can  be  shown  by  examination  with  an  opaque 
enema. 

Case  136,932,  male,  aged  47  years,  conductor.  Four  years  ago  in  a 
railway  accident  his  chest  was  crushed' by  logs  falhng  from  a  car. 
Following  this  he  began  to  have  severe  gastric  distress  about  two  hours 
after  meals.  At  times  the  pain  is  extreme.  It  is  made  worse  by  food. 
Relief  is  secured  by  abstinence  from  food  or  a  quick  physic.     JMeats, 


DIAPHRAGMATIC    HERNIA 


305 


Fig.  259. — Case  1.36,932.     Colon  after  operation. 


left  side. 


Ri^t^icLe. 


Fig.  260. — Case  136,932.     Note  the  left  diaphragm  after  repair.     The  broken  ribs  may 
also  be  seen  on  the  left  side. 
20 


306 


MISCELLANEOUS    GASTRIC    CONDITIONS 


potatoes  and  fruits  are  especially  distressing.  He  is  sometimes  con- 
scious of  gurgling  and  rumbling  in  the  left  chest.  Total  acidity  20; 
free  10;  combined  10.  Physical  examination  showed  displacement  of 
the  heart  to  the  right.  Under  forced  respiration  splashing  sounds  of 
fluid  and  air  were  heard  as  high  as  the  left  nipple.  Roentgen  findings : 
No  retention  from  six-hour  meal.  Stomach  high  up  in  left  chest,  is 
distorted  and  partially  rotated  (Fig.  256).  Old  fractures  of  left  ribs. 
Diagnosis:  Hernia  or  eventratio  diaphragmatica.     Colon  ray:  Spleoic 


Fig.  261. 


-Case  28,068.     Eluvatioii  of  left  diaphragm  (eventration). 
Barium  in  stomach,  s. 


flexure  in  left  thoracic  cavity.  Diagnosis:  Hernia  diaphragmatica 
(Fig.  257).  Findings  at  operation:  Hernia  through  left  diaphragm. 
Hernial  opening  about  6  inches  in  circumference.  Chest-cavity  con- 
tained part  of  small  intestine  and  the  greater  portion  of  the  colon 
spleen  and  stomach.  The  opening  was  sutured.  The  patient  also 
has  a  gastric  ulcer  on  the  lesser  curvature  about  1>^  inches  from  the 
pylorus,  and  an  ulcer  on  the  posterior  wall  of  the  duodenum  which  may 


GASTROPTOSIS  307 

require  operation  later.  (Neither  of  these  could  be  determined  at  the 
roentgen  examination,  because  of  the  malposition  and  distortion  of  the 
stomach.)  The  condition  after  operation  is  shown  in  Figs.  258,  259 
and  260. 

Case  28,068  (x-ray  No.  18,292),  male,  aged  58  years.  The 
patient  complains  of  shortness  of  breath  on  exertion.  He  has  noticed 
this  for  ten  years  or  more.  No  pains  in  left  chest.  He  has  known  for 
ten  years  that  his  heart  is  on  the  right  side.  No  marked  tympany  at 
left  base;  slight  change  in  note.  Breath  sounds  distant.  Vocal 
fremitus  much  diminished  at  left  base.  Coin  sound  not  typical  but 
rings  with  coin  just  inside  left  nipple.  Tinkhng  sounds  from  stomach 
heard  in  front.  Signs  not  definite.  The  roentgenogram  (ventro- 
dorsal view),  Fig.  261,  shows  the  high-arched  diaphragm  reaching  to 
the  fourth  costal  interspace.  Its  unbroken  outline  can  be  traced 
throughout.  Beneath  the  diaphragm  is  the  stomach  containing  a 
small  quantity  of  bismuth  food.  The  heart  shadow  lies  entirely  to  the 
right.  On  fluoroscopy  both  arches  of  the  diaphragm  moved  in  unison 
during  respiration. 

GASTROPTOSIS 

Notwdthstanding  a  wealth  of  literature  on  the  subject  of 
gastroptosis  there  is  still  widespread  disagreement,  not  only  as 
to  its  significance  and  proper  treatment,  but  even  as  to  W'hat 
constitutes  the  condition.  The  w^ork  of  Glenard,  who  is  gen- 
erally credited  with  the  first  detailed  descriptions  of  ptosis  of 
the  thoracic  and  abdominal  viscera,  attracted  a  large  retinue 
of  followers,  especially  during  the  past  two  decades.  Nephro- 
ptosis received  the  bulk  of  attention  for  some  years,  and  its 
rise  and  decline  in  clinical  and  surgical  favor  is  a  familiar  story. 
Later,  gastroptosis  and  enteroptosis  came  into  greater  promi- 
nence, and  have  been  given  recent  emphasis  by  Lane's  w^ork  on 
stasis. 

The  lexicographer  has  no  difficulty  in  defining  gastroptosis 
(or  the  preferred  form,  gastroptosia)  as  a  "dow-nward  displace- 
ment of  the  stomach."  But  here,  as  wdth  many  other  medical 
terms,  the  definition  is  by  no  means  equivalent  to  a  description 
of  the  condition,  nor  does  it  carry  an  unvarying  meaning.  At 
first  thought  gastroptosis  appears  to  be  a  simple  term  w^hich 
designates  a  specific  thing,  yet  the  most  casual  scanning  of  the 


308  MISCELLANEOUS   GASTRIC    CONDITIONS 

literature  reveals  a  broad  divergence  of  opinions  as  to  what 
gastroptosis  is. 

The  clinical  conception  of  gastroptosis  was  based  originally 
on  the  physical  signs  obtained  after  inflation  of  the  stomach,  the 
patient  being  examined  in  the  recumbent  position  usually.  The 
stomach  was  outlined  by  percussion  and  the  umbilical  level  was 
taken  as  the  normal  limit  of  the  lower  gastric  pole.  Descent 
of  the  greater  curvature  below  this  level  was  regarded  as  indica- 
tive either  of  gastroptosia,  or  gastrectasia,  or  both  combined. 
Then  came  the  roentgenologic  method  of  examination  with  the 
opaque  meal.  Patients  were  examined  in  the  standing  position 
as  a  rule,  but  the  umbilical  landmark  for  the  greater  curvature 
was  retained.  Consequently,  roentgenologists  were  annoyed  to 
find  that  the  majority  of  stomachs  fell  below  the  normal  stand- 
ard. Hampered  by  this  fixed  idea,  the  effort  to  establish  a 
normal  roentgenologic  stomach  which  would  harmonize  with 
the  normal  clinical  stomach  was  laborious.  Many  condemned 
the  roentgenologic  stomach  as  an  artefact.  It  was  contended 
that  the  weight  of  the  bismuth  dragged  the  stomach  far  below 
its  natural  level  and  distorted  its  form.  In  respect  to  this  con- 
tention it  should  be  stated  that  while  the  stomach  does  lie  at 
a  lower  level  when  the  patient  is  standing  than  when  he  is  re- 
cumbent, the  difference  is  not  due  to  any  extraordinary  weight 
of  the  opaque  meal. 

Nevertheless,  the  general  acceptance  of  gastroptosis  as  an 
important  entity  has  obliged  many  roentgenologists  to  attempt 
its  diagnosis.  As  a  result  they  offer  conflicting  diagnostic 
criteria.  Hertz^°  states  that  "complete  gastroptosis  is  present 
when  the  stomach  is  not  only  abnormally  low  in  the  erect  posi- 
tion, but  the  greater  curvature  reaches  below  the  umbilicus  in 
the  horizontal  position."  Kaestle^^  says:  ''If  the  greater  curva- 
ture of  a  stomach,  not  dilated,  stands  below  the  navel,  with  a 
more  or  less  high-lying  pylorus  above,  one  speaks  of  gastropto- 
sis." On  the  other  hand,  GroedeP^  puts  pyloroptosis  in  the 
first  place,  recognizing  it  by  the  course  of  the  pars  horizontalis 
superior,  the  low  position  of  the  pylorus  and  its  abnormal  mo- 


GASTROPTOSIS  309 

bility.  Further,  he  notes  fundus-ptosis,  resulting  in  a  small  gas- 
bubble.  Schlesinger^^  holds  that  the  cardia  must  take  part  in 
the  ptotic  process.  Of  greater  indicative  value  than  sinking  of 
the  pylorus,  he  thinks,  is  its  turning  out  of  its  original  horizontal 
position  into  a  vertical  or  left  oblique  direction.  He  sums  up 
the  three  factors  in  gastroptosis  as  follows:  (1)  Lengthening  of 
the  gastric  wall.  (2)  Drawing  down  of  the  cardia  and  upper 
pole  of  the  stomach.  (3)  Sinking  and  rolling  up  of  the  pylorus, 
Beclere  and  MerieP'^  point  out  that  the  stomach  never  leaves 
its  attachment  to  the  diaphragm.  They  prefer,  therefore,  to 
speak  of  the  ''lengthened  stomach"  rather  than  the  "ptosed 
stomach."  They  distinguish  two  kinds  of  lengthened  stomach; 
one  with  normal  tone,  tubular  in  form;  the  other  atonic,  with 
expanded  lower  pole,  inclining  to  delayed  motility. 

In  our  discussion  of  the  normal  stomach  (Chapter  VI)  we 
have  endeavored  to  emphasize  the  relation  of  the  form  and  posi- 
tion of  the  stomach  to  gastric  tone,  abdominal  tension  and — chief 
of  all — the  habitus  of  its  possessor.  Habitually  in  eateroptotic 
persons  and  quite  often  in  persons  of  normal  build,  we  have 
found  the  lower  gastric  pole  far  below  the  umbilical  level.  In 
most  instances  no  definite  gastric  symptoms  existed.  When 
they  did  exist  the  stomach  was  usually  found  to  be  anatomically 
normal  at  operation,  and  the  symptoms  were  explained  by  the 
discovery  of  some  other  lesion  within  the  abdomen.  On  the 
whole,  we  are  quite  willing  to  record  the  opinion,  from  a  roent- 
genologic standpoint,  that  the  position  which  the  stomach  occu- 
pies in  the  abdominal  cavity  is  its  least  important  characteristic. 

The  clinical  status  of  gastroptosis  is  likewise  somewhat  pre- 
carious. Recent  writers  on  diseases  of  the  stomach  speak  guard- 
edly of  ptosis.  Bassler^^  says  that  "the  special  objective  signs 
that  constitute  a  prolapsed  stomach  are  to  some  extent  still  a 
matter  of  personal  equation  with  each  observer."  Stockton^^ 
states  that  "gastroptosis  is  usually  unaccompanied  by  symp- 
toms sufficierrtly  specific  to  lead  one  to  suspect  its  presence." 
Much  of  the  import  of  gastroptosis  rests  on  the  assumption  of 
gastric  drainage  by  gravity,  a  conception  which  Cannon  regards 


310  MISCELLANEOUS   GASTRIC    CONDITIONS 

as  unfortunate.  The  functioning  of  the  pylorus  and  the  gastric 
tone  have  far  more  effect  upon  gastric  motihty  than  the  height 
of  the  pylorus  above  the  lower  pole.  The  low-lying  stomach 
is  usually  hypotonic,  and  for  the  latter  reason  is  likely  to  show 
moderate  delay  of  evacuation,  but  we  have  not  seen  a  delay  be- 
yond six  hours  from  this  cause  alone.  Lack  of  familiarity  with 
the  numerous  surgical  lesions  in  other  parts  of  the  digestive 
tract,  even  entirely  outside  of  it,  which  give  rise  to  gastric 
symptoms,  is  possibly  accountable  for  many  of  the  diagnostic 
favors  which  have  been  bestowed  upon  gastroptosis.  Zealous 
use  of  the  roentgen-ray  in  the  search  for  abnormalities  of  the 
stomach  is  seldom  unrewarded,  and  some  degree  of  '^gastropto- 
sis" is  the  rule  rather  than  the  exception. 

The  roentgen-ray  will  show  the  position  of  the  stomach,  and 
the  roentgenologist  may,  indeed  he  should,  report  this  as  a  detail 
of  his  findings  to  the  physician  in  charge.  But  the  examiner 
should  not,  as  is  sometimes  done,  inform  an  enteroptotic  hypo- 
chondriac that  his  trouble  is  a  ''dropped  stomach,"  and  thus 
give  the  patient  additional  cause  for  somber  introspection.  It 
is  doubtful  whether  the  roentgen  examiner  is  ever  justified  in  a 
diagnosis  of  "gastroptosis,"  in  view  of  the  varying  weight  which 
attaches  to  the  term.  Responsibility  for  this  diagnosis  belongs 
to  the  patient's  medical  counselor.  Though  we  are  not  here 
directly  concerned  with  the  treatment  of  gastroptosis,  whether 
medical  or  surgical,  the  following  remarks  by  Stiller"  are 
interesting. 

"Surgery,  intoxicated  by  its  triumphal  invasion  into  the 
domain  of  the  internist,  has  brought  out  various  operative 
methods  in  the  treatment  of  gastroptosis,  which  correspond  to 
the  narrow  gross  anatomical  viewpoint.  If  the  atonic  stomach 
is  too  broad,  they  cut  out  a  piece  of  the  gastric  wall ;  if  it  has  sunk 
down,  they  stitch  it  up,  shorten  it  by  folding  it,  fasten  it  to  the 
liver,  or  fix  it  to  the  rib-cartilages,  in  order  to  eliminate  the  re- 
spiratory movability  which  a  wise  nature  has  provided.  Por- 
tions of  the  weak  abdominal  wall  have  actually  been  excised. 
From  the  standpoint  of  the  asthenia  this  is  all  raw  vandalism. 


REFERENCES  311 

For,  wholly  apart  from  the  fact  that  suppressing  the  symptoms 
does  not  mean  the  cure  of  the  great  underlying  asthenic  trouble, 
we  cannot  as  yet  regard  the  stomach  as  simply  an  anatomical 
pouch;  it  has  indeed,  so  to  speak,  a  physiologic  importance.  If 
there  is  impairment  of  its  motor  function,  which  the  surgeons 
wish  to  improve  by  their  operative  arts,  it  will  not  be  made 
better  by  a  resection-scar,  by  stitching  up,  by  folding,  or  by 
fixation  to  the  belly- wall,  whereby  the  natural  movability  of  the 
organ  is  directly  harmed." 

REFERENCES 

1.  BuTTERWORTH,  W.  W. :  ''Hair-ball  or  Hair-cast  of  the  Stomach 

and  Its  Occurrence  in  Children."     Jour.  A.  M.  A.,  1909,  liii, 
617-623. 

2.  Moore,  G.  A. :  ''Hair-cast  of  the  Stomach  with  Report  of  a  Case." 

Bos.  Med.  and  Surg.  Jour.,  1914,  clxx,  8-11. 

3.  BuRCHARD,    A.:  "Bezoare   in   der   alten   und   in   der   modernen 

Medizin."     Fortschr.  a.d.  Geb.  d.  Rontgenstrahlen,  1914-15,  xxii, 
321-326. 

4.  Franke:  "Trichobezoar."     Korrespondenzblatt  des  Meckl.   Arz- 

tevereinbundes,  Nr.  343.     Quoted  by  Burchard,  loc.  cit. 

5.  ScHWARz,  G.:  "Ein  Fall  von  Trichobezoar."     Lijekcnickivijesnik 

1913,  XXXV,  38-44,  Rev.  Zentralhl.  f.  Chir.,  1913,  xl,  1571. 

6.  Kampmann,  E.:  "Ein  Trichobezoar  im  Magen."     Munchen.  Med 

Wchnschr.,  1911,  Iviii,  413-414. 

7.  Clairmont,  p.  and  Haudek,  M.:  "Die  Bedeutung  der  Magen- 

radiologie  ftir  die  Chirurgie."     Jena,  Fischer,  1911,  98. 

8.  HtJTTENBACH,  F. :  "Ein  Fall  von  Trichobezoar  des  Magens  bei 

Infantilismus."     Mitt.  a.d.  Grenzgeb.  d.   Med.  u.   Chir.,    1912, 
xxiv,  85-107  (with  29  references). 

9.  Holland,  C.  T. :  "Radiography  in  a  Case  of  Hair-ball  in  the 

Stomach."     Arch.  Roentgen  Ray,  1913,  xviii,  46-47. 

10.  Ramsbottom,   a.   and  Barclay,   A.   E.:  "The   Diagnosis   of   a 

Hair-ball  in  the  Stomach."     Arch.  Roentgen  Ray,  1913,  xviii, 
- 167-169. 

11.  Falconer,  A.  W. :  "A  Case  of  Congenital  Diverticulum  of  the 

Stomach."     Lancet,  1907,  i,  1296. 

12.  Mayo,    C.    H.:  "Diverticula    of    the    Gastro-intestinal    Tract." 

Jour.  A.  M.  A.,  1912,  lix,  260-264. 


312  MISCELLANEOUS    GASTRIC    CONDITIONS 

13.  GirriN,    H.    Z.:  ''The    Diagnosis    of    Diaphragmatic    Hernia." 

Annals  of  Surgery,  1912,  Iv,  388-397. 

14.  Becker,    T.  :  "Rontgenuntersuchungen   bei   Hernia   und   Even- 

tratio  diaphragmatica."     Fortschr.  a.d.  Geh.  d.  Rontgenstrahlen, 
1911,  xvii,  183-195. 

15.  Sailer,  J.  and  Rhein,  R.  D.:  "Eventration  of  the  Diaphragm." 

Amer.  Jour.  Med.  Sci.,  1905,  cxxix,  688-705. 

16.  Arnsperger,  H. :  ''Ueber  Eventratio  diaphragmatica."     Deutsch. 

Arch,  fur  Jdin.  Med.,  1908,  xcih,  88-97. 

17.  Kiekbock,  R.  :  "Ein  Fall  von  Zwerchfellhernie  mit  Rontgenim- 

tersuchung."     Ztschr.  f.  Uin.  Med.,  1907,  Ixii,  321-330. 

18.  HiLDEBRAND,  H.  and  Hess,  0.:  "Zm-  Differentialdiagnose  zwis- 

chen  Hernia  diaphragmatica  und  Eventratio  diaphragmatica." 
Miinclien.  Med.  Wchnschr.,  1906,  hi,  745-748. 

19.  Koniger,  H.:  "Zm'  Differentialdiagnose  der  Zwerchfellhernie." 

Munchen.  Med.  Wch7ischr.,  1909,  Ivi,  282-285. 

20.  Hertz,    A.    F.:  "Gastroptosis."     Arch.    Radiology    and   Electro- 

therapy, 1915,  XX,  143-150. 

21.  Kaestle,    K.:    ''Roentgenkmide."      Rieder-Rosenthal,    Leipzig, 

Earth,  1913,  i,  516. 

22.  Groedel,  F.  M.:  "Grundriss  and  Atlas  der  Roentgendiagnostik." 

Miinchen,  Lehmann,  1914,  390. 

23.  ScHLESiNGER,  E. :  "Weitere  Aufschltisse  iiber  den  Befund  und  die 

Genese   der   Gastroptose   durch   das   Rontgenbild."     Deutsch. 
Arch.  f.  hlin.  Med.,  1912,  cvh,  552-572. 

24.  Beclere  et  Meriel:  "L'exploration  radiologique  dans  les  affec- 

tions chirurgicales  de  I'estomac  et  de  Tintestin."     Ann.  internat. 
de  chir.  gastro-intest.,  1912,  vi,  132;  190. 

25.  Bassler,  a.:  "Diseases  of  the  Stomach."     Philadelphia,  Davis, 

1913,  708. 

26.  Stockton,    C.    G. :  "Diseases    of    the    Stomach."     New    York, 

Appleton,  1914,  .540. 

27.  Stiller,  B.:  "Die  asthenische  Konstitutionskrankheit."     Stutt- 

gart, Enke,  1907,  222. 


CHAPTER  XV 
THE  STOMACH  OF  INFANTS  AND  CHILDREN 

Flesch  and  Peteri/  who  examined  72  children  by  the  roent- 
gen method,  state  that  the  normal  stomach  of  infants,  ''filled  with 
physiologic  fluid  food, "  has  the  form  of  a  bagpipe,  has  a  large  gas- 
bubble,  is  horizontally  situated,  and  shows  no  peristalsis.  When 
given  pap-hke  food,  the  air-bubble  is  smaller,  the  stomach  shows 
a  descending  and  a  horizontal  portion,  and  peristalsis  is  present. 
Alwens  and  Husler^  find  that  the  form  and  position  of  the  infant 
stomach  depends  on  the  amount  of  filling,  position  of  the  body, 
etc.,  and  manifests  peristalsis  with  both  fluid  and  pap-like  foods. 
They  found  the  evacuation-time  for  fluid  food  to  be  about  three 
hours,  but  occasionally  they  noted  small  bismuth  residues  after 
five  hours  in  healthy  sucklings.  The  normal  evacuation  time 
of  200  c.c.  of  pap  is  from  three  to  three  and  a  half  hours. 

Ladd^  observed  a  curious  lack  of  peristalsis  in  the  normal 
infant's  stomach  as  compared  with  that  of  adults.  The  stomach 
appeared  to  squeeze  out  the  food  by  contracting  as  a  whole  upon 
its  contents,  seldom  showing  the  marked  indentations  so  char- 
acteristic of  peristaltic  waves  in  the  adult.  In  the  normal  case, 
he  states,  some  of  the  food  appears  in  the  small  intestine  as  soon 
as  the  plate  can  be  taken  after  feeding.  The  emptying  process 
goes  on  rapidly  at  first,  the  major  part  of  the  contents  being  ex- 
pelled in  from  one  and  one-half  to  two  and  one-half  hoars,  both 
in  breast-fed  and  bottle-fed  babies.  After  two  hours  there  is  a 
slowing  of  the  emptying  process  and  four  to  five  and  a  half  hours 
may  elapse  before  all  traces  of  bismuth  disappear.  In  one  case, 
a  normal  baby,  he  noted  a  considerable  residue  after  seven  and 
one-half  hours.  The  age  of  the  child  and  its  individual  pe- 
culiarities, the  quantity  and  composition  of  the  food,  may  all  be 
factors  influencing  gastric  motility.     The  suggestion  is  strong, 

313 


314  THE    STOMACH   OF   INFANTS   AND    CHILDREN 

he  observes,  that  the  casein  of  cow's  milk  when  given  in  high  per- 
centage decidedly  prolongs  the  evacuation-time.  If  the  casein 
is  precipitated  before  giving  it,  emptying  is  greatly  accelerated. 
The  presence  of  fat  has  no  retarding  action,  and  in  some  cases 
seems  to  favor  the  exit  of  the  gastric  contents. 

Sever^  examined  83  children  to  find  the  position  of  the  lower 
gastric  border.  The  stomachs  were  nearly  all  of  the  fish-hook 
form,  and  plates  were  made  with  the  patient  standing.  The 
lower  border  was  at  the  fourth  lumbar  vertebra  in  25 ;  at  the  level 
of  the  iliac  crests  in  9 ;  and  well  below  the  crests  in  49,  often  3  or 
4  inches  below.  He  thinks,  therefore,  that  a  low-lying  stomach 
in  a  child  does  not  necessarily  mean  a  pathologic  ptosis. 

Willox^  concludes  that  the  shape  of  the  stomach  with  con- 
tents in  children  is  not  a  fixed  one,  but  presents  many  differences 
during  the  process  of  digestion.  As  a  rule,  in  infants  the  shape  is 
more  or  less  globular,  becoming  elongated  and  J-shaped  as  the 
child  grows  older.  He  found  the  average  emptying-time  of  the 
stomach  to  be  three  and  three-quarters  hours,  and  thinks  that 
the  composition  of  the  food  has  less  effect  than  bulk  and  con- 
sistence on  gastric  motility.  In  some  cases  the  food  begins  to 
pass  through  the  pylorus  practically  as  soon  as  the  meal  has  been 
taken,  while  in  others  there  appears  to  be  a  resting  stage  before 
peristalsis  commences. 

Pisek  and  Le  Wald^  in  their  investigations  used  10  per  cent, 
bismuth  subcarbonate  fed  by  gavage.  They  concluded  that 
there  is  no  definite  normal  type  of  stomach  in  the  infant.  It  is 
horizontal  rather  than  vertical  in  position  as  compared  with  the 
adult  stomach.  They  noted  three  forms,  the  ovoid  (bagpipe), 
the  tobacco-pouch  (retort-shape)  and  the  pear-shape.  The 
shape  of  the  stomach  seems  to  depend  largely  on  the  quantity  of 
gas  which  it  contains  or  acquires,  and  the  amount  of  gas  is  less 
when  semi-solid  food  is  taken.  The  Rieder  hook-form  was  ob- 
served only  once,  occurring  in  a  six-months-old  infant.  The 
lesser  curvature  often  was  not  clearly  outlined.  In  the  majority 
of  cases  the  pylorus  was  comparatively  high  and  behind  the  py- 
loric  third.     Food   passed   out   rapidly.     A   large   number   of 


CONGENITAL   PYLORIC    STENOSIS  315 

stomachs  practically  emptied  themselves  within  an  hour.  The 
stomach  tends  to  expel  its  gas  accumulation  soon  after  the  entry 
of  food,  to  diminish  in  size  generally  and  to  shorten  its  axis  by 
drawing  upward  and  to  the  left. 

CONGENITAL  PYLORIC  STENOSIS 

While  the  symptom-complex  of  vomiting,  visible  peristalsis 
and  palpable  pyloric  tumor  is  deemed  pathognomonic  of  infantile, 
pyloric  stenosis,  the  aid  of  the  roentgenologist  is  sometimes 
solicited,  especially  in  the  spastic  and  atypical  cases.  Opinions 
as  to  the  value  of  the  roentgen  examination  are  contradictory. 
La  Fetra^  thinks  that  the  roentgen-ray  is  not  at  all  essential  for 
the  diagnosis  and  is  often  misleading.  Richter^  says  that  it 
cannot  be  relied  on  implicitly,  as  bismuth  will  pass  through  the 
pylorus,  though  slowly,  in  some  cases  of  stenosis.  Reuben^  re- 
gards the  roentgen-ray  as  of  little  value.  He  mentions  a  case 
which  he  sent  to  a  roentgenologist,  who  told  the  mother  of  the 
child  that  an  operation  would  be  necessary  as  no  bismuth  passed 
into  the  duodenum  during  twenty  minutes'  observation,  although 
Reuben  states  that  the  patient  was  doing  perfectly  well  under 
medical  care. 

On  the  other  hand,  Dunn  and  HowelP°  found  the  method 
useful  in  determining  the  degree  of  pyloric  obstruction,  the 
emptying- time  and  size  of  the  stomach.  Their  experience  in- 
cluded 6  cases  of  pyloric  spasm,  6  of  complete  stenosis  and  3  of 
partial  stenosis. 

Le  Wald,^^  whose  observations  have  been  extensive,  argues 
strongly  for  the  roentgen  examination.  He  presents  a  series  of 
roentgenograms  showing  different  grades  of  pyloric  obstruction. 
In  one  instance  some  of  the  meal  is  seen  going  through  the 
pylorus  early;  operation  was  not  performed.  In  another  case 
none  of  the  meal  passed  out  into  the  duodenum,  even  up  to 
fifty-two  minutes  after  ingestion,  and  operation  was  regarded  as 
imperative  (Fig.  262).  Dilatation  was  also  marked  in  the  latter 
case. 


316  THE    STOMACH   OF   INFANTS   AND    CHILDREN 

From  the  material  published  it  would  appear  on  the  whole, 
that  the  roentgen-ray  can  give  substantial  aid  in  the  diagnosis  of 
congenital  pyloric  stenosis,  whether  spastic  or  organic.  Cer- 
tainly the  degree  of  pyloric  patency,  the  time  required  for  gas- 
tric evacuation  and  the  presence  or  absence  of  dilatation  can  be 
determined  better  by  this  than  by  any  other  means.  The 
differentiation  of  organic  from  spasmodic  stenosis  ought  to  be 
possible  by  a  reexamination  after  giving  belladonna  or  papaver- 
ine, though  we  have  found  no  recorded  instance  in  which  these 


°-4* 


Fig.  262. — Congenital  pyloric  stenosis  in  an  infant  eight  weeks  old.  No  bismuth 
passing  the  pylorus  up  to  fifty-two  minutes.  (From  Le  Wald,  in  Johnson's  Thera- 
peutics.) 

drugs  were  thus  employed  in  infants.  The  opinions  above 
quoted,  adverse  to  the  value  of  the  roentgen  examination,  doubt- 
less arose  from  faulty  technic  or  incautious  interpretation  of  the 
results.  Admitting  our  absolute  lack  of  personal  experience 
with  the  roentgen  manifestations  of  infantile  pyloric  stenosis,  we 
would  venture  to  suggest,  nevertheless,  that  the  examiner  should 
be  careful  in  basing  a  diagnosis  upon  the  early  rate  of  gastric 
evacuation  alone.  In  adults  we  have  repeatedly  seen  instances 
in  which  no  barium  was  seen  to  pass  the  pylorus  for  a  consider- 
able time  after  its  ingestion,  yet  no  organic  stenosis  existed,  and  it 
is  not  irrational  to  suppose  that  this  might  also  occur  in  infants. 
It  would  seem  that  the  examiner  should  take  account  not  only 
of  the  initial  pyloric  outflow  but  also  of  the  total  time  required 


AEROPHAGY    IN    INFANTS  317 

for  gastric  evacuation,  the  presence  or  absence  of  gastric  dilata- 
tion, and  the  total  clinical  picture. 

AEROPHAGY  IN  INFANTS 

Leven  and  Barret^'-  agree  with  other  observers  that  the  nor- 
mal infant  stomach  contains  considerable  air.  While  nursing, 
the  air  is  usually  expelled  in  proportion  as  the  stomach  is  filled. 
But  they  have  seen  cases  in  which  the  air  was  not  expelled  and 
gave  rise  to  vomiting.  Immediately  after  nursing,  the  quantity 
of  milk  in  the  stomach  would  be  quite  small  and  the  air-bubble 
very  large,  lifting  up  the  left  half  of  the  diaphragm.  Then  there 
would  be  a  sudden  contraction  of  the  stomach  followed  by  vom- 
iting. In  such  a  case  if  the  infant  was  given  more  abundant 
nursiugs  at  longer  intervals  the  air  was  expelled  and  replaced  by 
the  milk,  and  vomiting  averted.  Leven  and  Barret  also  noted 
another  type  of  air-retention  and  vomiting,  which  they  believed 
was  due  to  a  spasm  of  the  cardia.  The  same  phenomena  were 
observed  radioscopically  as  in  the  other  type,  except  that  the  air 
was  at  no  time  expelled,  and  spasm  of  the  cardia  was  deemed  to 
be  the  cause.  In  order  to  lessen  the  intragastric  tension,  small 
but  frequent  feedings  were  employed. 

Regarding  the  teaching  in  most  training  schools  for  nurses, 
that  the  baby  should  be  kept  in  the  horizontal  position  after 
nursing.  Smith  and  Le  Wald^^  state:  ^' Air  is  swallowed  with  food 
by  many  if  not  all  infants.  The  erect  posture  favors  eructation 
of  this  air;  the  horizontal  posture  prevents  it.  The  horizontal 
posture,  by  preventing  eructation,  is  an  important  cause  of 
vomiting,  colic,  indigestion  and  disturbed  sleep."  They,  there- 
fore, advise  that  the  infant  be  held  upright  before  and  after 
feeding  to  encourage  eructation  of  the  air.  Feeding  should  be 
given  at  as  long  intervals  as  possible,  they  believe,  and  each 
feeding  should  not  be  given  too  slowly. 

REFERENCES 

.  1.  Flesch  and  Peteri:  Cited  by  Alwens  and  Husler. 
2.  Alwens,    W.    and    Husler,    J.:  " Roentgenuntersuchung    des 
kindlichen   Magens."     Verhandl.    d.    deutsch.   King.  f.   innere 
Med.,  1912,  xxix,  168-170. 


318  THE   STOMACH    OF  INFANTS  AND    CHILDREN 

3.  Ladd,  ]\I. :  ''The  Influence  of  Variations  of  Diet  upon  Gastric 

Ivlotilitj-  in  Infants."     Arch.  PediaL,  1913,  xxx,  740-746. 

4.  Sever,  J.  V. :  "  The  Position  of  the  Stomach  in  Children."     Arch. 

Pediai.,  1914,  xxxi,  38-44. 
.5.  WiLLOX,   L. :  "Gastric    Radioscopy   in    Children."     Practitioner, 
1915,  xcv,  599-641. 

6.  PiSEK,  G.  R.  and  Le  Wald,  L.  T.:  "The  Further  Study  of  the 

Anatomy  and  Physiology  of  the  Infant  Stomach  Based  on 
Serial  Roentgenograms."  Am.  Jour.  Dis.  Child.,  1913,  vi,  232- 
244. 

7.  La  Fetra,  L.  E. :  "The  Roentgen-ra}^  as  a  Diagnostic  Help  to  the 

Pediatrist."     Arch.  Pediat.,  1914,  xxxi,  761-763. 

8.  RicHTER,  H.  M. :  "Congenital  Pyloric  Stenosis."     Jour.  A.  M.  A., 

1914,  Ixii,  353-356. 

9.  PtEHBEN,  jNI.  S.:  "Pjdoric  Stenosis  in  Infancj^"     Arch.  Pediat., 

1914,  xxxi,  809-828. 

10.  DuxN,  C.  H.  and  Hottell,  W.  W. :  "Diagnosis  and  Treatment  of 

Pyloric  Stenosis  and  Pjdoric  Spasm."  Arch.  Pediat.,  1915, 
xxxii,  42&-433. 

11.  Le  Wald,  L.  T.:  In  Johnson,  A.  B.:  "Operative  Therapeusis." 

New  York,  Appleton,  1915,  iv.  212-214. 

12.  Leven,   G.  and  Barret,   G.:  "Radioscopie  Gastrique."     Paris, 

Doin,  1909,  180-186. 

13.  Smith,  C.  H.  and  Le  Wald,  L.  T.:  "The  Influence  of  Posture  on 

Digestion  in  Infancy."  Am.  Jour.  Dis.  Child.,  1915,  ix,  261-282, 


CHAPTER  XVI 
THE   STOMACH   AFTER   OPERATION 

Operations  most  commonly  performed  upon  the  stomach  in- 
clude gastrojejunostomy,  gastroduodenostomy,  sleeve  resec- 
tion, partial  gastrectomy  with  gastro-enterostomy,  pyloroplasty, 
gastrostomy,  gastropexy,  gastroplication  and  local  resection  of 
ulcers  or  tumor-bearing  areas.  After  any  of  these  interventions 
a  roentgen  examination  is  often  advantageous  in  determining  the 
functional  behavior  of  the  operated  stomach  and  finding  the 
cause  of  an  occasional  unsatisfactory  result.  When  a  gastro- 
jejunostomy has  been  made,  information  is  sometimes  desired 
as  to  the  exact  site  of  anastomosis,  the  patency  of  the  stoma  and 
the  general  mechanical  results  of  the  operation.  After  a  re- 
section for  cancer  the  question  of  a  possible  recurrence  is  of  deep 
interest. 

One  of  the  most  elaborate  studies  of  the  enterostomized 
stomach  is  that  by  Hartel,^  who  reports  his  findings  in  22  cases. 
In  several  cases  as  the  stomach  was  filled  with  the  bismuth  meal, 
it  was  noticed  that  the  ingesta  lagged  below  the  air-bubble. 
Filling  of  the  pyloric  portion  was  often  slower  than  normal. 
Before  the  stomach  was  completely  filled,  evacuation  through 
the  stoma  commenced.  In  every  case  the  contents  passed  rather 
freely  through  the  anastomosis,  and,  in  some  cases,  through  the 
pylorus  also.  Emptying  took  place  in  from  one  to  three  hours. 
In  7  of  the  cases,  the  flow  through  the  stoma  was  intermittent. 
In  1  case  it  was  rhythmic  and  synchronous  with  inspiration. 
The  periodic  flow  in  the  other  cases  corresponded  to  the  peristal- 
tic waves.  Hartel  believes  that  a  peristaltic  wave  passing  over 
the  stoma  tends  to  narrow  it  momentarily,  and  that  this  ex- 
plains the  intermittent  outflow  which  by  others  has  been  ascribed 
to  the  new  development  of  a  sphincter-mechanism  at  the 
stoma.     Owing  to  the  rapid  emptying  of  the  enterostomized 

319 


320  THE  STOMACH  AFTER  OPERATION 

stomach,  it  is  rather  difficult  to  determine  its  size  as  compared 
with  that  before  operation.  Most  writers  agree  that  there  is  a 
shrinkage.  Hartel  indorses  this  view  and  attributes  it  to  an 
increase  of  tone,  and  thinks  that  the  process  takes  place  gradually 
in  the  course  of  several  months.  He  did  not  observe  any  marked 
alterations  of  peristalsis. 

From  a  study  of  6  cases  in  which  posterior  gastro-enterostomy 
had  been  performed,  and  from  a  review  of  cases  reported  by 
others,  Outland,  Skinner  and  Clendening-  conclude  that  gastro- 
enterostomy if  properly  done  is  a  drainage  operation,  and  that  if 
the  stoma  is  at  the  lowest  part  of  the  stomach  in  the  erect  posi- 
tion, the  food  leaves  the  stomach  almost  exclusively  by  the 
gastro-enterostomy  opening,  the  stomach  emptying  with  great 
rapidity.  In  cases  in  which  the  gastro-enterostomy  does  not 
quite  drain  the  stomach,  the  food  leaves  both  by  the  stoma  and 
the  pylorus. 

Case^  thinks  that  gastro-enterostomized  stomachs  may  be 
divided  into  three  classes : 

1.  Those  with  a  very  large  gastro-enterostomy  opening,  the 
food  dropping  in  an  apparently  passive  way  from  the  stomach 
into  the  small  bowel.  These  patients,  he  says,  frequently 
complain  of  a  sickening  distress,  especially  after  the  ingestion 
of  a  meal  consisting  largely  of  warm  Uquid,  and  Case  attributes 
the  distress  to  sudden  overdistention  of  the  small  bowel. 

2.  The  stomachs  which  do  not  empty  well  after  the  opera- 
tion, probably  not  because  the  opening  is  too  small,  but  because 
it  is  placed  too  high  or  too  far  from  the  pylorus.  The  stomach 
empties  quickly  until  the  level  of  the  opening  is  reached,  after 
which  it  empties  very  slowly,  the  residue  at  that  time  remaining 
for  eight,  ten  or  more  hours. 

3.  The  normally  functioning  cases — those  patients  in  whom 
the  passage  of  material  from  the  stomach  occurs  very  much  as  in 
the  normal  patient.  A  few  moments  elapse  before  food  is  seen  in 
the  jejunum,  the  passage  of  food  boluses  is  irregularly  intermit- 
tent, and  the  total  time  required  for  clearance  of  the  opaque 
meal  averages  from  four  and  a  half  to  six  hours. 


AFTER    GASTRO-ENTEROSTOMY  321 

Case  found  also  that  unless  organic  pyloric  obstruction  existed, 
it  was  the  rule  to  find  some  of  the  barium  passing  through  the 
pylorus  as  well  as  through  the  stoma.  In  several  cases  in  which 
the  pylorus  was  blocked  by  mattress  sutures,  it  became  patent 
again  as  early  as  the  fifth  or  sixth  week  after  operation.  In  2 
out  of  4  cases  in  which  pyloroplasty  had  been  done,  Case  was 
able  to  confirm  Cannon's  and  Blake's  finding  that  too  rapid 
exit  of  food  from  the  stomach  was  prevented  by  the  formation 
of  rhythmically  contracting  constriction  rings  in  the  duodenum. 
At  times  he  also  noted  analogous  phenomena  after  gastro-jejun- 
ostomy,  namely,  a  sort  of  sphincter-action  in  the  jejunum  at  a 
point  3  to  6  cm.  below  the  gastrojejunal  opening. 

Obviously  it  is  impossible  to  define  closely  the  normal,  ex- 
pected and  desirable  conditions  following  operation.  These  will 
depend  largely  upon  the  particular  case  at  hand,  the  nature  and 
extent  of  the  original  lesion,  and  the  character  of  the  intervention, 
which  is  often  controlled  by  circumstances  rather  than  choice. 
Yet  some  conception  of  what  may  be  considered  the  normal  se- 
quences of  operation  is  necessary  for  the  judgment  of  abnormal 
results.  Customarily,  after  a  gastrojejunostomy  we  have  ob- 
served the  following : 

1.  The  opaque  meal  passes  freely  through  the  stoma.  This 
is  the  rule,  with  rare  exceptions,  even  after  the  lapse  of  years. 
The  flow  through  the  anastomosis  may  be  continuous,  intermit- 
tent, or  rhythmic.  It  is  perhaps  somewhat  more  voluminous 
and  continuous  shortly  after  operation  than  it  is  when  months 
or  years  have  elapsed,  but  the  stoma  does  not  tend  to  contract 
materially  as  time  goes  on. 

2.  Unless  the  pylorus  is  obstructed  by  the  original  lesion  or 
was  blocked  at  operation,  a  part  of  the  gastric  contents  may  pass 
through  the  pylorus  spontaneously,  or  can  usually  be  driven 
through  it  by  manipulation.  When  the  pylorus  has  been 
blocked  at  operation  it  may  reopen  within  a  few  weeks  or 
months.  As  a  rule,  even  with  a  patent  pylorus,  the  bulk  of 
evacuation  apparently  takes  place  through  the  stoma. 

3.  There  is  no  retention  from  the  six-hour  meal  in  the  stom- 


322  THE    STOMACH   AFTER    OPERATION 

ach,  duodenum,  or  jejunal  loop.  The  stomach  empties  ia  con- 
siderably less  time  than  the  normal  unoperated  stomach.  We 
are  unable  to  endorse  Case's  theory-  that  after  gastro-enterostomy 
the  stomach  should  empty  preferably"  in  normal  time;  this 
result  would  militate  against  the  most  common  purpose  of  the 
operation. 

4.  The  stomach  is  usually  smaller  than  before  operation, 
unless  marked  dilatation  existed  previous^. 

5.  The  stomach  is  not  deformed  as  to  its  general  contour 
(unless  by  the  original  lesion  or  its  resection-scar),  and  has  no 
tendency  toward  hour-glass  form  or  spastic  distortion. 

6.  The  gastric  contour  at  the  stoma  is  not  usually  deformed 
saving  occasionally  a  slight,  smooth,  incurvation  at  that  point. 

7.  Extensive  adhesions  about  the  stoma  simply  as  a  result  of 
operation  are  uncommon,  and  the  stomach  is  at  least  moderately 
mobile. 

8.  Peristalsis  is  not  overactive.  If  there  is  any  change  at  all, 
it  would  seem  to  be  toward  lessened  activity. 

9.  The  efferent  jejunum  is  neither  narrowed  nor  dilated  nor 
markedly  irregular  in  outline. 

10.  The  duodenum  is  not  dilated. 

Any  departure  from  this  summary  should  be  viewed  with 
mistrust,  but  should  be  carefully  interpreted  in  conjunction  with 
the  surgical  and  chnical  histories.  Figs.  263,  264  and  265  illus- 
trate presumably  normal  conditions  folloT^ing  gastro-enter- 
ostomy, the  roentgen  examination  showing  no  evidence  of 
secondary  pathology,  and  the  patients  having  no  symptoms 
demanding  further  surgery. 

After  a  sleeve  resection,  the  stomach,  besides  being  diminished 
in  size  proportionately  to  the  amount  exsected,  may  also  show 
more  or  less  hour-glass  contraction  at  the  suture  hne,  or  an  in- 
cisura  at  that  point  on  the  greater  curvature  (Fig.  266).  In 
time  such  a  constriction  tends  to  become  less  pronounced.  If 
only  a  small  gastric  sac  remains  as  a  result  of  the  resection,  its 
capacity  gradually  increases  to  some  extent.  Faulhaber  and 
V.  Redwitz'*  observed  circular  contraction  at  the  site  of  a  sleeve 


GASTROJEJUNOSTOMY 


323 


Fig.  263. — Normal  conditiou  after  gastrojejunostomy.  Stoma  at  s.  Meal  leaving 
stomach  chiefly  through  gastro-enterostomy,  though  some  barium  has  passed  the 
pylorus. 


Fig.  264. — Normal  condition  after  gaatrojejunostomy.  The  patient  was  corpulent 
and  the  pressure  of  the  abdomen,  while  the  plate  was  being  made,  displaced  the  stomach 
upward  into  a  transverse  position.  The  undeformed  stoma  is  seen  at  s.  Pylorus 
patent. 


324 


THE  STOMACH  AFTER  OPERATION 


Fig.  265.- 


-Normal  condition  after  gastrojejunostoui\'.      Stoma  at  s. 
barium  passing  into  duodenum. 


Small  amount  of 


Fig.  266.- 
tomosis,  ■ 


-Stomach    after    sleeve-resection,    showing    contracture    at    point    of    anas- 
(Other  details  of  this  case  will  be  found  in  the  chapter  on  Gastric  Ulcer.) 


RESECTION  325 

resection,  and  this  was  associated  with  a  small  stomach  which 
emptied  rapidly  through  the  pylorus. 

Following  an  extensive  ablation  of  the  pyloric  portion,  clos- 
ure of  the  duodenum  and  making  a  gastro-enterostomy,  the 
remnant  of  the  stomach  shows  as  a  small,  vertically  hanging 
pouch,  with  the  stoma  at  the  lowest  point.  Subsequently  the 
pouch  enlarges  to  a  degree.  It  should  be  smoothly  contoured, 
pliable  and  expansible,  if  all  diseased  tissue  has  beenl^removed 
(Fig.  267). 


Fig.  267. — Stomach   after    resection,    duodenal    closure,  gastro-enterostomy. 
Roentgenologically  normal. 


Pyloroplasty  obliterates  the  normal  constriction  at  the  ring 
and  the  duodenal  loop  merges  directly  into  the  gastric  cavity. 
Gastric]  drainage  is  copious  and  the  evacuation- time  is  shortened. 

The  few  cases  of  gastropexy  (for  ptosis)  which  we  have  ex- 
amined did  not  show  any  roentgenologic  signs  of  the  operation. 

Cohn,^  in  three  patients  upon  whom  gastrostomy  had  been 
performed,  noted  persistent  hour-glass  contraction  at  the  site  of 
the  opening.     Notwithstanding  a  notable  lack  of  peristalsis  the 


326  THE    STOMACH   AFTER   OPERATION 

gastric  contents  were  rather  rapidly  and  continuously  evacuated 
through  an  open  pylorus. 

The  roentgenologic  determination  of  post-operative  compli- 
cations is  not  easy  because  of  the  inevitable  physical  and  func- 
tional changes  incident  to  operative  intervention.  To  safeguard 
his  conclusions,  the  examiner  should  be  informed  as  fully  as 
possible  concerning  the  conditions  found  at  operation,  what  was 
done,  and  the  subsequent  clinical  history.  Roentgenograms 
made  prior  to  operation  are  especially  valuable  for  comparison 
with  those  made  after. 

The  important  complications  following  gastric  surgery  in- 
clude jejunal  or  gastrojejunal  ulcer,  so-called  vicious  circle,  and 
recurrence  or  new  development  of  cancer  or  ulcer.  Concerning 
these  the  roentgen  examination  can  often  give  fairly  precise  in- 
formation. Besides  these  candidly  pathologic  conditions,  un- 
satisfactory results  are  sometimes  due  to  imperfect  surgical 
technic.  Since  surgeons  differ  widely  among  themselves  as  to 
technical  details,  it  is  not  in  the  province  of  the  roentgenologist 
to  decide  whether  or  not  a  gastro-enterostomy  opening  is  too 
large  or  too  small,  too  high  or  too  near  the  pylorus,  or  whether 
the  afferent  jejunal  loop  is  of  proper  length.  But  the  a;-ray 
should  show  the  site  of  the  stoma,  its  patency,  and,  with  an  un- 
obstructed pylorus,  the  length  of  the  afferent  loop.  Final 
judgment  in  these  matters  may  be  left  to  those  directly  con- 
cerned. 

JEJUNAL  AND  GASTROJEJUNAL  ULCERS 

Ulcers  developing  in  the  vicinity  of  the  stoma  after  gastro- 
jejunostomy have  been  variously  designated  jejunal  and  gastro- 
jejunal ulcers.  A  post-operative  ulcer  situated  in  the  jejunum 
well  away  from  the  gastro-enterostomy  opening,  is,  strictly 
speaking,  jejunal.  An  ulcer  involving  the  stoma,  both  on  its 
gastric  and  jejunal  aspects,  is  more  properly  described  as  gastro- 
jejunal. 

Paterson^  was  among  the  first  to  draw  attention  to  these 
ulcers,  and  in  his  comprehensive  article  collected  51  cases  from 


JEJUNAL    AND    GASTROJEJUNAL    ULCERS  327 

the  literature.  Other  cases  have  been  reported  by  W.  J.  Mayo/ 
Moynihan  and  Tatlow/  Mayo-Robson^  and  Soresi.^°  In  1915, 
one  of  us  (Carman)  m  collaboration  with  Balfour^^  collected  13 
cases  from  the  records  of  this  clinic,  and  since  then  additional 
cases  have  come  under  observation.  All  of  these  were  of  the 
gastrojejunal  type,  and  we  shall  confine  ourselves  to  that  term 
in  subsequent  discussion.  All  post-operative  ulcers  in  the  neigh- 
borhood of  the  stoma,  whether  involving  it  or  not,  have  pre- 
sumably similar  causes,  and  have  like  symptoms,  so  that  their 
designation  is  immaterial. 

An  important  etiologic  factor  appears  to  be  the  use  of  a  con- 
tinuous suture  of  unabsorbable  material  in  making  the  anastomo- 
sis, silk  or  linen  sutures  being  found  at  the  site  of  the  ulcer  in 
many  instances.  However,  these  ulcers  have  also  occurred  after 
the  use  of  the  Murphy  button. 

Pathologically,  they  are  usually  of  considerable  surface  ex- 
tent, with  much  induration  and  hyperemia.  The  line  of  anas- 
tomosis is  usually  involved,  but  the  ulcer  tends  to  spread  further 
on  the  jejunal  than  on  the  gastric  side.  Adhesions  were  present 
in  the  majority  of  our  cases. 

Clinically,  they  do  not  give  rise  to  any  symptoms  or  signs 
which  can  be  considered  definitely  diagnostic.  After  a  variable 
period  of  relief  by  the  gastro-enterostomy,  the  patient  again 
develops  pain  and  other  symptoms,  often  somewhat  like  those 
prior  to  operation,  but  without  any  fixed  and  decisive  complex. 
Any  aid  to  the  discovery  of  these  ulcers  is,  therefore,  of  distinct 
value.  The  results  in  our  own  cases  convince  us  that  by  the 
roentgen-ray  such  aid  can  be  obtained,  and  that  in  many  in- 
stances the  condition  can  be  positively  diagnosed. 

Post-operative  ulcers  perforating  into  the  colon  have  previ- 
ously been  given  passing  mention  by  roentgenologists,  but  simple 
gastrojejunal  ulcers  have  not  heretofore  been  extensively  stud- 
ied from  the  roentgen  viewpoint.  Mathieu  and  Savignac^^ 
state  that  in  jejunal  ulcer  perforating  into  the  large^bowel,  the 
direct  passage  of  bismuth  into  the  colon  can  be  demonstrated. 
They  state  further  that  the  colon  may  be  narrowed  by  adhesoins 


328 


THE   STOMACH   AFTER   OPERATION 


about  the  fistula,  and  the  small  intestine  may  be  dilated  in  all  or 
parts  of  its  length,  which  conditions  are  susceptible  of  demon- 
stration by  roentgenoscopy.  Their  remarks  seem  to  be  based 
largely  on  5  cases  of  jejunocolic  fistula  reported  by  Lion  and 
Moreau.^^  One  of  these  was  examined  with  the  roentgen-ray 
by  Beclere.  Moynihan  and  Tatlow's  case  of  gastrojejunal 
ulcer  was  rayed  by  Rowden,  but  his  report  was  non-committal. 

Barsony^^  reports  a  case  of  gastrojejunal  ulcer  in  which  the 
roentgen-ray  showed  a  pocket  at  the  line  of  anastomosis,  the  size 
^_iiLalkrone>.  Some  five  hours  later  the  pocket  was  still  filled  with 
bismuth  after  the  stomach  was  empty.  Barsony  lays  strong 
emphasis  on  the  persistence  of  bismuth  in  the  ulcer-cavity  as  a 
characteristic.  But,  excepting  one  of  the  cases  hereinafter 
reported,  we  have  not  noted  any  roentgenologic  evidence  of  a 
cavity  resembling  the  niche  of  penetrating  gastric  ulcer  or  the 
accessory  pocket  of  perforating  ulcer.  The  nature  of  the  ulcer 
rather  precludes  any  probability  of  visualizing  its  crater  as  a 
niche,  for  the  reason  that  the  ulcer  is  most  often  characterized 
by  surface  area  rather  than  depth. 

In  a  series  of  14  cases  in  this  clinic  examined  by  the  roentgen- 
ray,  all  were  of  the  non-fistulous  type,  yet  all  but  2  showed  dis- 
tinct signs  of  secondary  pathology.  These  manifestations  in- 
cluded deformity  about  the  stoma,  narrowing  and  deformity  of 
the  efferent  jejunum,  diminished  patency  of  the  stoma,  dilatation 
of  the  stomach,  retention  from  the  six-hour  meal,  hyperperistal- 


RoENTGEN  Findings  in  Fourteen  Cases  of  Gastrojejunal  Ulcer 

Case  Number 


Roentgen-ray  findings 


Deformity  about  stoma 

Exaggerated  peristalsis 

Large  stomach 

Gastro-enterostomy  not  freely  pa- 
tent  

Retention  from  six-hour  meal.  ... 
Lessened  mobility  of  stomach.  ... 

Dilatation  of  duodenum , 

Spacticity  of  stomach 

Irregularity  of  jejunum 


+  ,  + 
+  '  - 
+  .  - 

+  :  - 
+  ■  + 


+  +  +1  + 
-  !  -  +■  + 
_  i  +  + 


-  ;  -   -'  + 


Mod. 


+ 


+  ,  + 
+  '  + 


+  '  + 


Mod. 


-      + 


Mod. 

+ 
+ 


+ 


^^ 


S      ^ 


+ 
+ 

i- 


i- 


JEJUNAL    AND    GASTEOJEJUNAL    ULCER  329 

sis,  dilatation  of  duodenum,  and  spasticity  of  the  stomach.  The 
accompanying  tabulation  shows  the  number  of  cases  in  which 
such  findings  were  noted  and  their  association  with  each  other. 

Deformity  about  the  stoma  of  a  posterior  gastro-enterostomy 
is  often  not  readily  visible.  If  the  point  of  anastomosis  is  well 
up  on  the  vertical  portion  of  the  stomach,  an  oblique  view  may 
show  it,  but  it  is  much  more  commonly  on  the  horizontal  part  of 
the  stomach.  Here  an  oblique  view  is  of  little  service,  and  we 
have  often  found  it  advantageous  to  lift  up  the  overhanging 
lower  border  of  the  stomach  by  manual  pressure  and  thus  expose 
the  anastomosis.  With  a  high  anterior  or  posterior  gastro- 
enterostomy a  lateral  view  may  be  of  value.  While  a  gastro- 
enterostomy often  produces  a  little  dimpling  at  the  point  of 
attachment,  there  is  ordinarily  no  marked  irregularity.  On  the 
other  hand,  in  approximately  four-fifths  of  our  cases  of  gastro- 
jejunal  ulcer,  rather  striking  deformity  about  the  stoma  was 
observed.  Gastrojejunal  ulcer  following  an  anterior  gastro- 
enterostomy sometimes  produces  a  palpable  inflammatory  mass 
which  corresponds  to  the  visible  irregularity  and  filling-defect 
about  the  stoma.  This  finding  is  almost  pathognomonic.  Since 
a  gastro-enterostomy  is  often  in  the  median  line,  pressure  against 
the  spine  may  deform  this  part  of  the  stomach,  and  the  examiner 
should  be  careful  in  his  interpretation  of  plate  findings.  The 
patient's  abdomen  should  not  be  pressed  too  tightly  against  the 
plate,  and,  if  prone,  his  chest  and  shoulders  should  be  supported 
by  cushions,  or  a  table  with  a  deep  fenestrum  for  the  plate  should 
be  used.  However,  if  the  distortion  about  the  stoma  is  marked 
and  identical  on  all  plates  the  observer  is  safe  in  saying  that  it  is 
abnormal. 

Narrowing  of  the  jejunum  and  deformity  of  its  contour  was 
present  in  more  than  half  the  cases  of  gastrojejunal  ulcer.  It 
involved  the  efferent  limb,  usually  quite  near  the  stoma.  To^be 
of  value,  this  sign  must  be  definite  and  constant  at  the  screen 
inspection  and  on  all  plates. 

A  lack  of  free  patency  of  the  stoma  was  notable  in  several 
instances.     The  signs  of  this  condition  are  both  direct  and  in- 


330  THE    STOMACH   AFTER   OPERATION 

direct.  Directly,  the  examiner  can  note  the  lessened  amount 
of  barium  passing  out,  in  contrast  to  the  normal  copious  exit. 
If  the  flow  is  scant  or  wanting  in  spite  of  manipulation  of  the 
gastric  contents  toward  the  stoma,  it  is  reasonably  certain  that 
the  opening  is  not  free.  If  originally  made  ample,  contraction 
of  the  orifice,  though  unusual  and  somewhat  indicative  of  gastro^ 
jejunal  ulcer,  is  not  absolutely  so.  We  have  recently  noted  a 
case  in  which  narrowing  was  found  at  operation  but  without  any 
evidence  of  ulcer.  However,  in  this  instance  the  stoma,  though 
narrow,  was  not  deformed. 

Indirectly,  obstruction  may  be  manifested  by  a  retention 
from  the  six-hour  meal,  or  by  the  large  size  of  the  stomach. 
Gastric  hyperperistalsis,  or  dilatation  of  the  duodenum  or  affer- 
ent limb  of  the  jejunum,  may  also  be  in  evidence.  Of  these 
signs  the  six-hour  retention  is  most  important.  Occurring  in  a 
gastro-enterostomized  stomach,  it  is  highly  significant  of  ob- 
structed drainage.  In  most  of  the  cases  of  retention  in  associa- 
tion with  gastrojejunal  ulcer,  the  retention  was  between  the 
stoma  and  pylorus.  In  one  case  the  barium  rest  was  in  the 
immediate  neighborhood  of  the  stoma,  as  though  held  in  a  small 
pouch.  This  proved  to  be  a  gross  ulcer  with  a  jejunal  pocket  of 
considerable  size,  being  exaggerated  by  adhesions.  The  unre- 
sected  enterostomized  stomach,  even  though  large  before  opera- 
tion, tends  to  contract  to  normal  or  even  smaller  dimensions.  If 
then  it  does  not  show  diminution  in  size,  but  is  still  large,  inter- 
ference with  its  emptying  may  be  suspected.  Another  common 
sequence  of  obstruction  is  an  exaggeration  of  peristalsis.  An 
increase  in  the  vigor  and  number  of  the  waves  may  also  result 
from  other  causes,  so  that  this  sign  is  merely  indicative  of  some 
abnormal  condition.  Dilatation  of  the  duodenum  was  observed 
in  one  of  our  cases,  and  this  may  or  may  not  have  been  due  to 
obstruction  by  the  ulcer  at  the  stoma. 

Lessened  mobility  of  the  stomach  was  noted  in  two  instances, 
and  was  the  result  of  extensive  adhesions  about  the  stoma.  But 
this  is  a  sign  of  which  the  observer  can  rarely  be  confident,  espe- 
cially when  dealing  with  a  posterior  gastro-enterostomy.     By 


JEJUNAL    AND    GASTROJEJUNAL    ULCER  331 

palpation,  changing  tlie  position  of  the  patient,  and  requiring 
him  to  breathe  deeply,  fixation  at  the  point  of  anastomosis  can 
sometimes  be  fairly  determined. 

Spasticity  of  the  stomach  as  seen  in  one  case,  with  extensive 
irregularity  of  the  gastric  borders,  cannot  be  considered  very 
significant,  except  as  an  indication  of  reflex  irritation. 

In  translating  these  signs  into  a  diagnostic  opinion,  the 
examiner  should  be  fully  acquainted  with  the  entire  clinical  and 
surgical  history  of  the  case,  not  for  the  purpose  of  anticipating 
the  roentgen  findings,  but  to  prevent  hasty  deduction  from  them. 
The  roentgen  phenomena  of  gastrojejunal  ulcer  fall  into  two 
groups — those  broadly  denoting  an  abnormal  condition,  and 
those  pointing  directly  to  the  seat  of  trouble.  Six-hour  reten- 
tion, hyperperistalsis,  large  size  of  the  stomach,  dilatation  of  the 
duodenum,  and  spasticity  of  the  stomach,  are  included  in  the 
first  group.  They  may  be  noted  singly  or  in  varying  combina- 
tions. The  second  group,  namely,  deformity  about  the  stoma, 
narrowing  and  irregularity  of  the  jejunum,  scant  flow  of  barium 
through  the  gastro-enterostomy  opening,  and  fixation  of  the 
stomach  at  the  site  of  anastomosis,  all  point  to  the  latter  as  the 
pathologic  focus,  and  here  gastrojejunal  ulcer  is  by  far  the  most 
common  lesion.  After  resection  of  the  stomach  for  cancer, 
similar  signs  may  result  from  recurrence  of  the  growth  at  the 
point  of  gastro-enterostomy;  the  history  should  aid  in  making  the 
distinction.  Peculiarities  or  errors  of  surgical  technic  may  also 
produce  some  of  the  roentgenologic  manifestations  enumerated 
above,  and  in  view  of  this  possibility,  the  roentgen  diagnosis  of 
gastrojejunal  ulcer  should  be  guarded. 

However,  a  careful  consideration  of  all  the  circumstances 
should  decide  whether  or  not  further  surgical  intervention  is 
necessary,  and  this  is  more  important  than  an  exact  diagnosis. 

Case  33,109,  male,  aged  51.  Stomach  trouble  for  the  last  twelve 
years.  Pain  localized  to  pit  coming  on  two  or  three  hours  after  eating; 
relieved  by  food.  Three  or  four  spells  a  year  lasting  three  or  four  weeks 
at  a  time.  Some  nausea;  vomits  frequently.  Total  acidity,  58;  free 
HCl,    44;    combined,    14.     Food    remnants,    1.     Clinical    diagnosis: 


332 


THE  STOMACH  AFTER  OPERATION 


Fig.  268. — Case  33,109.     Gastrojejunal  ulcer.     Irregularity  of  stoma  and  jejunum 

shown  at  s. 


Fig.  269. — Case   112,375.     Gastrojejunal  ulcer.     Deformity  about  stoma  at  s 
Narrowed  jejunum,  j. 


JEJUNAL    AND    GASTEOJEJUNAL    ULCER 


333 


Duodenal  ulcer.  Operative  findings:  January  18,  1910.  Large  con- 
tracted ulcer  duodenum.  Operation:  Posterior  gastro-enterostomy. 
Subsequent  history:  June  8,  1915.  Following  operation  the  patient 
was  well  for  five  years;  then  there  was  an  onset  of  same  complaint, 
coming  with  the  change  in  the  weather  for  several  days  at  a  time.  Pre- 
meal  distress  and  food-ease.  Condition  has  progressed  rapidly;  dis- 
tress almost  continuous;  vomiting  of  retained  food.  Weight  loss 
from  162  to  126.  No  urinary  disturbance.  S.B.P.  118,  D.B.P.  80. 
No  masses  felt,  rectal  shelf  free.  Total  acidity,  28;  free  HCl,  20;  com- 
bined 8.     Roentgen  findings :  Retention  one-fourth  the  six-hour  motor 


Fig.  270. — Case  96,667.     Gastrojejunal  ulcer.     Deformity  of  stoma  at  s.     Narrowed 
jejunum,  j.     Note  hyperperistalsis ;  peristaltic  waves  at  p. 

meal.  Irregularity  of  stoma  and  jejunum.  Pylorus  not  freely  patent; 
gastro-enterostomy  only  moderately  so.  Diagnosis:  Gastrojejunal 
ulcer  (Fig.  268).  Operative  findings:  Very  large  gastrojejunal  ulcer, 
partly  in  the  stomach  and  partly  in  the  jejunum.  Pylorus  adherent  to 
abdominal  wall.  Linen  suture  found  hanging  in  the  ulcer.  Opera- 
tion: Separation  of  gastro-enterostomy.  Opening  in  stomach  closed 
Excision  of  ulcer.     Jejunum  reunited.     Gastroduodenostomy. 

Case  1 12,375,  male,  aged  42.  In  January,  1914,  gastro-enterostomy 
elsewhere  for  duodenal  ulcer,  following  excision  of  ulcer  and  closure 
of  pylorus.     After  the  operation  the  patient  had  a  great  deal  of  distress. 


334 


THE    STOMACH   AFTER   OPERATION 


In  August,  1914,  he  visited  the  Mayo  CHnic,  at  which  time  an  inde- 
terminate (post-operative)  diagnosis  was  made.  After  leaving  the 
dinic  he  returned  to  his  work,  but  the  distress  became  so  severe  that 
his  surgeon  operated  again  in  October,  1914,  and  found  adhesions  in 
the  neighborhood  of  the  stoma  with  a  mass  at  the  gastrojejunal 
juncture  and  a  linen  thread  hanging  in  it.  About  one  week  after  this 
operation  a  large  abscess  formed  in  the  wound,  which  has  continued 


Fig.  271. 


Fig.  272. 


Fig.  273.  Fig.  2  74. 

Figs.  271,272,  273,274. — Cases  of  gastrojejuna]  ulcer.     Stoma,  s.     Jejunum,  j. 

to  discharge  from  time  to  time.  In  probing  the  wound,  the  linen 
thread  was  removed.  Roentgen  findings:  No  retention  from  the  six- 
hour  meal.  Filling-defect  about  stoma  and  efferent  jejunum  (Fig. 
269).  Operative  findings:  Gastrojejunal  ulcer  in  which  was  hanging 
a  piece  of  linen  thread  8  inches  long.  Ulcer  involved  wall  of  transverse 
colon,  but  had  not  perforated  into  it.  Sinuses  communicating  with 
abdominal  wall.     Operation:  1.  Reunion  pyloric  end  of  stomach  and 


JEJUNAL   AND    GASTROJEJUNAL   ULCER 


335 


body   by  plastic.     2.  Divulsion  of  stricture   of  the   duodenum.     3. 
Gastro-enterostomy  cut  off.     Restoration  of  jejunum. 

Case  96,667,  male,  aged  51  years.     With  the  exception  of  a  violent 
pain  lasting  for  a  few  minutes  some  twenty  years  ago,  followed  by 


liG.  276, 


Fig.  275. 


Fig.  277. 

Figs.   275  to   278. — Cases  of    gastrojejunal  ulcer.     Stoma,  s.     Jejunum,  j.     Gastric 
ulcer,  u.     Hour-glass  stomach,  h.     Duodenum,  d. 

epigastric  soreness  and  jaundice,  the  patient  had  always  been  well 
until  twelve  years  ago,  when  a  period  of  intermittent  stomach  trouble 
developed,  lasting  for  a  couple  of  years.     These  attacks  were  usually 


336  THE    STOMACH   AFTER    OPERATION 

accompanied  by  epigastric  distress  coming  on  two  or  three  hours  after 
eating,  vdth.  food-ease.  For  the  last  nine  j'^ears,  more  or  less  constant 
complaint  with  pain  two  to  four  hours  after  eating  and  early  part  of 
night,  eased  b^^  soda,  food,  vomiting,  and  occasionallj^  b}^  lavage. 
Hemoglobin,  65  per  cent.  Reds,  3,540,000.  Urine  negative.  Was- 
sermann  negative.  Total  acidity,  80;  free  HCl,  52;  combined,  28. 
Roentgen  findings:  Fairlj^  large  stomach.  No  retention  from  the  six- 
horn-  motor  meal.  H^-perperistalsis;  deformity"  of  the  bulbus  duodeni. 
Diagnosis:  Duodenal  ulcer.  Operation:  December  12,  1913.  Per- 
forating duodenal  ulcer.  Gall-bladder  and  appendix  negative.  Pos- 
terior gastro-enterostomy.  Subequent  history:  Patient  returned 
October  5, 1914,  stating  that  he  had  been  comfortable  for  three  months, 
then  began  to  have  occasional  sharp  pain  and  vomiting.  During  past 
three  months,  trouble  almost  constant.  Roentgen  findings:  Large 
stomach  with  retention  one-half  the  six-hour  motor  meal.  Hyper- 
peristalsis;  gastro-enterostomj''  not  functionating  well.  Deformity  of 
stoma  (Fig.  270).  Operation:  October  12,  1914.  Finney  operation 
on  jejunum  for  jejunal  ulcer  at  old  gastro-enterostomy  opening,  size 
of  a  quarter.  Ulcer  caused  by  old  linen  suture  hanging  in  gastro- 
enterostomy opening. 

REGURGITANT  VOMITING  AND  VICIOUS  CIRCLE 

Persistent  regui'gitant  vomiting  after  gastro-enterostomy, 
the  vomit  ■asually  containing  more  or  less  bile,  is  the  principal 
symptom  of  what  is  commonly  designated  'Sdcious  circle." 
Shortly  after  operation  there  is  sometimes  regurgitant  vomiting, 
"which  ceases  after  lavage  or  other  treatment,  but  a  persistence  of 
this  vomiting,  which  rarely  occm^s,  is  indicative  of  mechanically 
obstructive  conditions  requiring  reintervention. 

Moynihan^^  classifies  four  varieties  of  misdirected  current, 
any  One  of  w^hich  establishes  the  circulus  vitio^us : 

1.  Regurgitation  of  duodenal  contents  through  the  pylorus. 

2.  Escape  of  fluids  from  the  stomach  into  the  afferent  loop. 

3.  Escape  of  fluids  from  the  afferent  loop  into  the  stomach. 
This  is  generally  considered  the  most  frequent  and  the  most 
grave  variety. 

4.  Regurgitation  of  the  contents  of  the  efferent  loop  into  the 
stomach. 


REGURGITANT  VOMITING    AND   VICIOUS    CIRCLE  337 

As  to  the  causes  of  regurgitant  vomiting,  Moynihan  cites  the 
following  suggestions  by  Chlumskij  :^^ 

''1.  Formation  of  a  spur.  This  is  certainly  the  most  fre- 
quent. When  the  anastomosis  is  effected,  the  two  limbs  of  the 
loop  hang  downward,  and  a  sharp  kink  with  spur-formation  re- 
sults at  the  point  of  junction. 

''2.  The  jejunal  displacement  may  cause  a  kink  at  the  duo- 
denal-jejunal  juncture,  and  thereby  produce  an  acute  obstruc- 
tion of  the  duodenum. 

^'3.  The  mucous  membrane  of  the  stomach  may  form  large 
pouting  valves  which  obstruct  the  afferent  opening. 

''4.  Closure  of  the  anastomotic  opening  if  the  muco-mucous 
stitch  is  improperly  applied. 

''5.  Compression  of  the  efferent  branch  of  the  loop  by  the 
colon  (Doyen). 

'^6.  Stendel  related  a  case  operated  upon  by  Czerny,  in 
which  the  opening  in  the  transverse  mesocolon  had  narrowed 
and  constricted  the  efferent  loop. 

"7.  In  the  original  operation  of  Wolfler,  the  antiperistaltic 
implantation  of  the  jejunum  favored  regurgitation." 

Moynihan  himself  believes  that  the  mechanical  defect  con- 
sists mainly,  if  not  solely,  in  leaving  a  loop  of  jejunum  between 
the  flexure  and  the  anastomosis.  The  loop  becomes  distended, 
''water-logged,"  and  thus  obstructive.  Besides  the  foregoing 
possible  and  proven  causes,  Finsterer  mentions  others,  including 
an  unduly  long  afferent  loop,  which,  when  filled,  compresses  and 
obstructs  the  efferent  limb.  He  also  emphasizes  still  another 
cause,  namely,  herniation  of  the  small  intestine  through  the 
sht  in  the  mesocolon,  thus  compressing  and  obstructing  the 
afferent  jejunum.  He  reports  an  instance  of  this  in  which  the 
roentgen  examination  showed  a  long  loop  of  the  upper  small 
bowel  distended  with  barium  to  the  size  of  a  child's  arm,  and 
confirming  the  diagnosis  of  stenosis. 

During  the  past  four  years  we  have  examined  by  theroentgen- 
ray  22  cases  of  regurgitant  vomiting  following  gastro-enteros- 
tomy,  all  of  which  were  reoperated.     With  two  exceptions,  the 


338  THE  STOMACH  AFTER  OPERATION 

original  operation  had  been  performed  elsewhere.  The  time 
that  had  elapsed  since  operation  ranged  from  one  month  to  ten 
years,  with  an  average  of  three  years.  In  twelve  of  these  cases 
the  roentgenologist  did  not  report  any  definite  evidence  of  sec- 
ondary pathology.  Some  of  the  examinations  were  made  early 
in  this  work  when  the  examiner  was  satisfied  with  determining 
the  patency  of  the  stoma  and  pylorus,  and  was  dubious  of  ob- 
taining any  additional  information.  It  is  noteworthy  also  that 
in  some  cases  of  regurgitant  vomiting  a  second  surgical  explora- 
tion fails  to  reveal  an  adequate  cause,  especially  in  those  cases 
which  have  had  a  gastro-enterostomy  performed  for  the  relief 
of  symptoms  and  without  demonstrable  pathology.  Many  sur- 
geons deem  these  latter  cases  to  be  particularly  prone  to  post- 
operative troubles. 

In  ten  of  our  cases  the  roentgen  examination  elicited  abnor- 
mal signs,  which  in  most  instances  were  indicative  of  grave  dis- 
turbance. In  the  main,  the  signs  were  those  of  obstruction,  as 
shown  by  retention  from  the  six-hour  meal,  large  size  of  the 
stomach,  failure  of  the  barium  to  pass  through  the  stoma,  and 
hyperperistalsis.  At  reoperation  various  conditions  were  found. 
In  three  instances  the  obstruction  was  due  to  adhesions.  In  one 
case  the  stricture  was  apparently  produced  by  contraction  of  the 
opening  through  the  gastrocolic  omentum,  and  in  another  case 
the  gastro-enterostomy  had  been  made  on  a  long  loop  which 
had  kinked.     Brief  details  of  four  cases  follow: 

Case  105,429,  man,  aged  39  years.  Chronic  indigestion  since  the 
age  of  ten.  Attacks  one  to  two  months  apart,  lasting  up  to  ten  days, 
consisting  of  fullness,  distress,  and  sour  eructations,  coming  irregularly 
after  meals,  and  with  irregular  food  relief.  In  later  years  a  sore  spot 
at  the  right  of  the  ensiform  was  present  in  the  attacks.  Six  years  ago 
he  had  a  gangrenous  appendix  removed,  and  was  quite  well  for  two 
years.  Then  the  old  trouble  recurred  daily  until  three  months  ago, 
when  he  had  an  acute  attack  of  pain  and  was  operated  upon  the  next 
morning.  A  posterior  gastro-enterostomy  (no  loop)  was  done  for 
what  was  believed  by  his  surgeon  to  be  a  duodenal  ulcer.  For  eleven 
clays  following  the  operation  he  vomited  large  quantities  of  yellowish 
fluid  every  half  hour.     After  this  the  vomiting  came  every  five  to 


REPORT    OF    CASES 


339 


ten  days,  each  time  vomiting  large  amounts  of  duodenal  content.  At 
present  he  can  only  take  about  6  ounces  of  food  at  a  time;  if  more  is 
taken,  regurgitant  vomiting  follows.  Roentgen  findings:  No  reten- 
tion. Rather  high  gastro-enterostomy.  The  roentgenogram  (Fig. 
279)  shows  a  very  large  amount  of  barium  in  the  afferent  loop  of 
the  jejunum,  while  very  little  is  seen  in  the  efferent  limb.  Where 
the  mechanical  conditions  are  normal,  the  reverse  is  true.  Because 
of  these  findings,  a  diagnosis  of  vicious  circle  was  made.  Findings 
at  operation:  Large  gastro-enterostomy  opening;  pylorus  patent. 
Many  adhesions  in  upper  abdomen.  No  ulcer  could  be  found,  either 
in  stomach  or  duodenum.     Operation:  Gastro-enterostomy  cut  off.' 


Fig.  279.— Case  105,429. 


Case  133,498,  man,  aged  51.  Posterior  gastro-enterostomy  a 
month  previously  for  duodenal  ulcer  with  impending  perforation, 
(This  had  been  diagnosed  roentgenologically  on  hyperperistalsis'and 
six-hour  retention.)  He  now  complains  of  vomiting  bitter,  green  fluid, 
at  times  slate-colored.  The  vomiting  occurs  mostly  from  9.00  p.m, 
to  1.00  a.m.  Total  acidity,  38,  free,  24;  combined,  14;  food  remnants,' 
filtrate  1,000  c.c.  Roentgen  findings:  Large  stomach  with  retention 
of  half  the  six-hour  motor  meal.  Irregular  vigorous  peristalsis. 
Nothing  seen  passing  thi'ough  stoma.  Some  barium  passing  pylorus 
(Fig.  280).     Findings  at  reoperation:  Stoma  greatl}^  strictured,  ap- 


340 


THE    STOMACH   AFTER   OPERATION 


parently   by   contraction    of    the    opening    through    the    gastrocolic 
omentum. 

Case  37,378,  man,  aged  47.  Gastro-enterostomy  one  year  ago, 
following  which  he  vomited  incessantly  for  ten  days.  Since  then  he 
has  continued  to  vomit  frequently,  often  daily  for  several  days.  Re- 
missions at  times  of  several  days  without  vomiting.  The  vomiting 
occurs  usually  some  hours  after  eating,  and  is  fluid  in  character,  food 
being  ejected  only  occasionally.  Gastric  analysis:  Total  acids,  36, 
free,  26;  combined,  10;  raisin-skins.     Roentgen  findings:  Large  stom- 


FiG.  2.S0. — Case  133,498.     Details  described  in  text. 


ach.  Retention  of  half  the  motor  meal.  No  evidence  of  gastro- 
enterostomy. Deformity  of  the  duodenal  bulb.  Dilatation  of  third 
portion  of  duodenum  (Fig.  281).  Findings  at  reoperation:  The 
gastro-enterostomy  had  been  made  on  a  4-inch  loop,  turned  to  the 
right.  Duodenal  ulcer  }^  inch  below  the  pylorus  (Enterostomy — 
Finney) . 

Case  141,212,  man,  aged  61.  The  patient  gave  a  history  of  having 
had  a  gastric  ulcer  excised  nine  years  ago,  and  a  gastro-enterostomy 
two  years  ago  for  subsequent  pyloric  stenosis.  After  the  second  opera- 
tion he  did  very  well  until  six  months  ago,  when  he  began  to  have 
occasional  projectile  vomiting.  This  has  gradually  become  more 
marked,  and  for  the  past  three  weeks  he  has  been  vomiting  every  other 


LESIONS    AFTER    OPERATION  341 

day.  Weight  loss  marked.  Gastric  analysis:  Total  acidity,  14;  all 
combined;  food  remnants  (raisin-skins);  filtrate  1000  c.c.  Roentgen 
findings:  Retention  of  three-fom'ths  the  motor  meal  (Fig.  282).  No 
barium  between  stoma  and  pylorus.  Gastro-enterostomy  obstructed 
(Fig.  283).  Findings  at  reoperation:  Large  gastric  ulcer  between 
stoma  and  pylorus,  which  had  contracted  until  the  stoma  was  almost 
closed.  (Resection  pyloric  end;  plastic  enlargement  of  gastro-enteros- 
tomy. On  microscopic  examination  of  the  resected  tissue,  cancer 
cells  were  found.) 


Fig.  281. — Case  37,378.     Description  in  text. 

RECURRENCE  AND  NEW  DEVELOPMENT  OF  LESIONS  AFTER 

OPERATION 

The  roentgenologic  demonstration  of  new  and  recurring 
lesions  after  operation  is  sometimes  feasible,  as  instanced  by 
the  following  cases: 

Case  89,460,  man,  aged  64.  Resection,  with  anterior  gastro- 
enterostomy one  year  ago  for  extensive  carcinoma  of  the  lesser  curva- 
ture of  the  stomach,  perforating.  The  patient  gained  25  poundslin 
weight  and  felt  well  until  five  months  ago.  He  now  has  heavy^distress 
after  meals  and  is  again  losing  weight.  Total  acidity,  10;  all  combined. 
Roentgen  findings:  No  retention.  Filling-defects  at  site  of  resection 
(Fig.  284).     Diagnosis:  Recurring  carcinoma;  inoperable. 


342 


THE   STOMACH   AFTEE   OPERATION 


Fig.  282. — Case  141,212.     Six-hour  retention  in  stomach.     Narrowing  of  stoma  at  s. 


Fig.  283. — Case  141,212.     Same  case  as  in  Fig.  280,  after  filling  stomach. 


KEPORT    OF    CASES 


343 


Case  75,677,  woman,  aged  47.  Resection  three-fifths  of  stomach 
with  anterior  gastro-enterostomy  for  cancer  of  the  pyloric  end  of  .the 
stomach,  one  year  ago.  Gained  weight  and  felt  well  until  three 
months  ago.  Since  then  bitter  regm'gitation,  occasional  vomiting, 
and  loss  of  appetite  and  strength.  Resistance  and  tenderness  in  right 
epigastrium.  Roentgen  findings:  No  retention  from  six-hour  meal. 
Filling-defect  at  site  of  resection  corresponding  to  palpable  mass  (Fig. 
285).     Diagnosis:  Recurring  carcinoma.     No  operation. 

Case  124,629,  man,  aged  44.  Mikulicz-Hartman-Polya  resection, 
three-fourths  of  stomach,  end  to  side  anastomosis,  for  cancer  involving 


A? 


Fig.  284. — Case  89,460.     Recurring  carcinoma  of  the  stomach  after  resection. 


all  of  stomach  except  cardiac  end,  nine  months  ago.  Now  complains 
of  poor  appetite,  distention  after  meals  and  weight  loss.  Roentgen 
findings :  No  retention.  Finger-print-like  filling-defects  extending  up- 
ward from  site  of  resection  (Fig.  286).  Diagnosis:  Recurring  cancer; 
inoperable. 

Case  81,588,  man,  aged  41.  Posterior  gastro-enterostomy  seven 
months  previously  elsewhere,  for  ulcer  of  the  lesser  curvature  just 
above  the  pylorus,  also  ulcer  on  the  greater  curvature  extending  into 
the  duodenum.  He  had  no  trouble  after  the  operation  except  an 
occasional  heaviness,  until  three  months  ago,  when  he  began  to  have 


344 


THE  STOMACH  AFTER  OPERATION 


Fig.  285. — Case  75,677.     Recurring  gastric  cancer. 


Fig.  286. — Case  124,629.     Recurring  cancer. 


REFERENCES 


345 


Fig.  287.- — Case  81,588.     Cancer  following  ulcer.     Filling  defect  at  /. 
Efferent  jejunum  at  j. 


Fig.  288. — This  patient  had  had  a  resection  of  the  pyloric  end  of  the  stomach  four 
years  previously  for  carcinoma  on  ulcer.  The  roentgenogram,  which  shows  a  filling 
defect  on  the  lesser  curvature  above  the  stoma,  is  indicative  of  a  recurrence.  However, 
no  corresponding  mass  could  be  felt  and  the  patient's  general  condition  was  good.  In 
the  absence,  therefore,  of  any  clinical  corroboration  it  was  thought  that  possibly  the 
filling  defect  was  the  result  of  the  operation.  A  reexamination  after  a  few  weeks  or 
months  would  determine  the  matter. 


346 


THE    STOMACH   AFTER    OPERATION 


Fig.  289. — Patient  had  had  a  V-resection  of  an  ulcer  on  the  greater  curv^ature,  body 
of  stomach.  The  roentgenogram  was  made  four  weeks  after  the  operation.  The  stom- 
ach, especially  the  pyloric  segment,  is  small  and  the  greater  curvature  is  irregular,  prob- 
ably the  result  of  the  operation,  and  not  of  any  new  pathologj-. 


Fig.  290. — Gastero-enterostomy  for  obstructive,  non-resectable  cancer  of  the  stomach. 


REFEEENCES 


347 


regurgitation  of  food  at  night.  About  four  weeks  ago  he  commenced 
to  have  severe  epigastric  pain  from  midnight  until  morning,  belching 
of  gas,  and  sour  eructations.  Roentgen  findings :  Gastro-enterostomy 
freely  patent.  No  retention  from  the  six-hour  meal.  Filling-defect 
lesser  curvature  (Fig.  287).  Diagnosis:  Lesion  of  the  stomach. 
Findings  at  exploration :  Inoperable  carcinoma  of  the  lesser  curvature 
with  glands  of  large  size  as  high  as  the  diaphragm.     Pancreas  enlarged. 


Fig.  291. — Case  81,479.  Posterior  gastro-enterostomy  three  years  previously  for 
gastric  ulcer,  lesser  curvature.  The  roentgenogram  shows  extensive  filling  defects  on 
both  curvatures,  due  to  the  development  of  cancer.  The  jejunal  loop  is  shown  in  its 
entirety. 


REFERENCES 

1.  Hartel,    F.:        "Die    Gastroenterostomie    im    Rontgenbilde." 

Deutsch.  Ztschr.  filr  Chir.,  1911,  cix,  317-395. 

2.  OuTLAND,  J.  H.,  Skinner,  E.  H.  and  Clendening,  L. :  ''A  Study 

of  the  Mechanism  of  the  Stomach  After  Gastro-enterostomy,  by 
Means  of  the  X-ray."  Surg.,  Gynec.  and  Ohstet.,  1913,  xvii, 
175-183. 

3.  Case,   J.   T.:  ''Roentgen   Studies  After   Gastric   and   Intestinal 

Operations."     Jour.  A.  M.  A.,  1915,  Ixv,  1628-1634. 

4.  Faulhaber,  M.  and  v.  Redwitz,  E.  F.:  "Ueber  den  Einflusz  der 

Zirkularen    Magenresection   auf   die   Sekretion  und  Motilitat 


348  THE    STOMACH    ATTEE    OPERATION 

des  Magens."  Med.  Klinik,  1914,  i,  680-684.  Ahst.  Fortschr. 
a.  d.  Geb.  d.  Rdntgenstrahle?i,  1914,  xii,  469. 

5.  CoHX,    M. :    "Die   Gastrostomie   im   Rontgenbild."     Fortschr.  a. 

d.  Geh.  der  Rdntgenstrahlen,  1914-15,  xxii,  377. 

6.  Pateesox,  H.  J.:    "Jejunal   and  Gastrojejunal  Ulcer  Following 

Gastrojejunostomy."     Annals  of  Surgery,  1909,  1,  367-440. 

7.  Mayo,   W.   J.:    "Gastrojejunal    Ulcers   (Pseudo-jejunal  Ulcers). 

Surg.,  Gynec.  and  Ohstet.,  1910,  x,  227-229. 

8.  MoTNiHAN,  B.  G.  A.  and  Tatlow,  E.  T.  :  "A  Case  of  Transgastric 

Excision  of  a  Gastrojejunal  Ulcer."     Lancet,  1914,  i,  739-740. 

9.  INIayo-Robsox:  Trails.  Roj^  Med.  Chir.  Soc,  1904,  Ixxxvii,  339. 

10.  SoRESi,  A.  L.:  "Secondarj'^  Ulcers  of  the  Stomach  and  Jejunum." 

Annals  of  Surgery,  1915,  Ixi,  328-333. 

11.  Car:max,  R.  D.  and  Balfour,  D.  C.:    "Gastrojejunal  Ulcers — 

Their  Roentgenologic  Aspects."  Jour.  A.  M.  A.,  1915,  Ixv, 
227-232. 

12.  IMathieu,  a.  and  Savigxac,  R. :  "Etude  sur  les  troubles  intesti- 

naux  consecutifs  a  la  gastro-enterostomie."  Arch.  d.  mat.  de 
I'app.  digestif.,  1913,  vii,  541. 

13.  Liox,    G.    and    Moreau,    Ch.  :     "La    fistule    jejunocolique    par 

ulcere  peptique  du  jejunum  a  la  suite  de  la  gastroenterostomie." 
Rev.  de  chir.,  1909,  xxxix,  873-896. 

14.  Baesony,  T.  :  "Beitrage  zur  Diagnostik  des  postoperativen  jeju- 

nalen  und  Anastomosenulkus."  Wiener  klin.  Wchnchr.,  1914, 
ii,  1058-1062. 

15.  ]\IoYxiHAN,  B.  G.  A.:  "Abdominal  Operations."     Philadelphia, 

W.  B.  Saunders  Co.,  1906,  201. 

16.  Chltjmskij,   v.:    "Ueber   die   Gastroenterostomie."     Beitrage  z. 

Klin.  Chir.,  1898,  xx,  231;  487. 

17.  FiNSTERER.    H. :  "Chronischer    Circulus    Vitiosus   nach    Gastro- 

enterostomie mit  Einklemmung  von  Dlinndarmschlingen  im 
IMesocolonschiitz."  Beitrage  z.  Klin.  Chir.,  1912,  Ixxxi,  341- 
360. 


^  CHx^PTER  XVII 

GALL-STONES  AND  DISEASE  OF  THE  GALL-BLADDER  AND 

LIVER 

GALL-STONES 

The  degree  of  precision  with  which  gall-stones  can  be  diag- 
nosticated by  the  roentgen-ray  is  a  moot  question.  Although 
efforts  to  demonstrate  biliary  calculi  began  early  in  the  history 
of  roentgenology,  the  first  trials  were  either  unsuccessful  or  suc- 
ceeded so  rarely  that  the  method  was  deemed  impracticable. 
Even  as  early  as  1899,  Carl  Beck/  of  New  York,  who  was 
perhaps  the  first  to  report  such  an  achievement,  exhibited  a 
roentgenogram  depicting  biliary  and  hepatic  calculi.  With  the 
gradual  advance  of  roentgenologic  technic  the  attempt  to  show 
gall-stones  was  frequently  renewed  and  was  more  often  rewarded 
by  positive  findings.  Still,  the  percentage  of  demonstrations 
has,  in  the  main,  been  discouragingly  small,  and  the  rank  and  file 
of  roentgenologists  have  had  little  cause  for  enthusiasm.  Lately, 
the  roentgenography  of  gall-stones  has  been  given  fresh  impetus 
by  such  men  as  Pfahler,  Case,  Cole  and  George. 

Pfahler/  who  was  among  the  first  in  this  country  to  take  up 
the  matter,  concluded  from  his  experiments  on  the  cadaver  in 
1901  that  the  roentgen  method  was  useless  and  unreliable.  In 
1914,  however,  Pfahler  was  able  to  find  stones  in  20  out  of  27 
operated  cases,  or  74  per  cent.  Nevertheless,  he  believes  that 
in  general  one  cannot  count  on  more  than  50  per  cent,  being 
demonstrable.  Technically,  he  places  the  patient  on  the  abdo- 
men with  the  plate  under  the  gall-bladder  region.  The  patient's 
arms  are  extended  and  the  upper  part  of  the  body  is  bent 
strongly  to  the  left  (not  rotated).  The  tube  (6  or  7  Benoist), 
with  compression-cylinder  diaphragm,  is  set  so  that  the  rays 
will  pass  obliquely  through  the  space  between  the  last  rib  and 
the  crest  of  the  ilium  toward  the  gall-bladder,  compression  being 

349 


350  DISEASES   OF   THE    GALL-BLADDER   AND    LIVER 

made  if  desired.  He  prefers  short  exposures,  but  without  the 
intensifying  screen,  and  agrees  with  Rubaschow^  that  several 
exposures  are  generally  necessary  with  different  tubes  and  dif- 
ferent timing.  Careful  oblique  illumination  of  the  finished 
plate  is  usually  necessary  to  bring  the  shadows  into  view. 

Case'^  believes  he  is  safe  in  the  opinion  that  when  gall-stones 
are  present  they  can  be  demonstrated  in  40  or  50  per  cent,  of  the 
cases.  He  prefers  to  look  for  them  in  the  course  of  an  examina- 
tion of  the  digestive  tract  with  the  bismuth  meal,  rather  than 
make  a  special  examination. 

Cole^  notes  that  during  the  last  few  years  several  roentgen- 
ologists have  detected  gall-stones  in  about  50  per  cent,  of  the 
cases  examined,  but  that  this  percentage  was  estimated  in  dif- 
ferent ways  by  different  men.  Cole  regards  catharsis  and  fast- 
ing as  an  essential  preliminary  to  plating.  Among  other  details 
favored  he  mentions  stereoscopic  plates,  and  double-screened 
plates  (two  plates,  back  to  back,  with  intensifying  screens  of 
different  speeds,  in  the  same  holder).  Superimposing  finished 
plates  and  thus  deepening  the  stone-shadows  assists  interpreta- 
tion. 

George  and  Leonard^  feel  that  85  to  90  per  cent,  of  gall- 
stones can  be  shown.  They  emphasize  the  use  of  an  extremely 
small  cone,  but  are  indifferent  as  to  the  employment  of  intensify- 
ing screens.  They  regard  preliminary  catharsis  with  its  result- 
ing gas  as  a  more  disturbing  factor  in  interpreting  plates  than  the 
fecal  contents  of  the  colon. 

CaldwelF  says:  "If  we  only  make  enough  plates  and  make 
them  well  enough,  we  can  obtain  suspicious  shadows  in  the  gall- 
bladder region  of  any  normal  individual.  The  interpretation  of 
gall-stone  plates,  therefore,  becomes  a  matter  involving  not  only 
skill  and  judgment,  but  temperament  as  well.  In  no  other  field 
of  roentgen  diagnosis  is  the  personal  equation  of  the  observer 
more  important.  This,  I  believe,  is  the  best  explanation  of  why 
some  observers  report  as  high  as  85  per  cent,  and  others  as  low 
as  5  per  cent,  of  successes  in  these  examinations.  The  greatest 
danger  of  the  x-rays  is  in  faulty  interpretation.     These  faults 


GALL-STONES  351 

usually  consist  in  reading  into  the  plates  something  which  is  not 
there.  The  clinical  indications  of  gall-stones  are  fairly  accurate, 
and  it  is  likely  that  stones  are  present  in  at  least  50  or  60  per 
cent,  of  those  cases  submitted  to  x-ray  examination.  Of  these 
perhaps  as  many  as  one-tenth  give  perfectly  definite,  reliable 
x-ray  shadows  of  gall-stones.  In  the  other  nine-tenths  of  the 
cases  examined,  some  of  the  x-ray  plates  will  show  hazy  and 
suspicious  shadows,  many  of  which  are  due  to  gall-stones.  If 
we  consider  all  these  hazy  and  suspicious  shadows  corrobora- 
tive evidence  of  gall-stones,  the  operation  will  vindicate  us  in 
the  majority  of  the  cases,  and  we  may  easily  overestimate  the 
help  actually  obtained  from  the  x-ray  plates.  We  must  be 
very  careful  lest  the  clinical  knowledge  we  have  of  the  patient 
may  lead  us  to  accept  as  evidence  of  gall-stoaes  x-ray  shadows 
such  as  might  be  found  in  some  of  the  x-ray  plates  of  any  nor- 
mal individual."  He  therefore  warns  against  regarding  as  proof 
of  gall-stones  ''any  x-ray  shadow  that  does  not  present  charac- 
teristics distinguishing  it  definitely  from  other  shadows,  and 
which  has  not  the  sharpness  of  outline  commonly  found  in 
other  calculi." 

Our  own  figures  do  not  compare  favorably  with  the  larger 
percentages  quoted  above,  notwithstanding  the  fact  that  abun- 
dant material  has  been  at  our  disposal.  Many  of  the  cases  gave 
typical  histories,  but  even  in  these,  although  extraordinary 
efforts  were  made,  we  have  been  able  to  obtain  diagnostic  shad- 
ows in  only  a  small  minority.  The  difficulty  has  been,  not  to 
find  shadows,  for  these  were  often  present,  but  to  find  shadows 
that  seemed  definite  and  characteristic.  The  personal  equation 
of  an  observer  is  not  open  to  argument,  and  sincere  endeavors 
to  advance  roentgenologic  diagnosis  should  not  be  disparaged. 
On  the  other  hand,  a  degree  of  conservatism  is  usually  wholesome 
and  corrective.  Taking  the  more  cautious  estimate  of  50  per 
cent,  of  successes  as  possibly  attainable,  the  examiner  may 
doubt  whether  a  strenuous  effort  to  find  gall-stones  is  worth 
while,  since  if  he  does  not  succeed,  the  chances  of  their  presence 
or  absence  remain  practically  as  before.     However,  he  is  not 


352  DISEASES   OF   THE    GALL-BLADDER   AND    LIVER 

justified  in  taking  this  attitude,  even  though  his  failures  far 
outnumber  his  successes.  But,  unless  he  is  unusually  fortunate, 
he  should  keep  in  mind  two  things:  First,  that  though  he 
may  fail  to  find  their  shadows,  stones  may  nevertheless  be 
present,  and  a  negative  roentgen  finding  should  be  ignored; 
second,  that  stones  are  incidental  and  not  essential  to  a  chole- 
cystitis which  may  necessitate  surgery.  C.  H.  Mayo^  has  said: 
''We  must  remember  that  infection  is  the  entity  and  gall-stones 
are  secondary  to  it ;  that  although  gall-stones  can  often  be  shown 
in  a  radiograph — surely  a  great  help — the  latter  cannot  show  the 
severe  infections,  the  papillary  cholecystitis,  soft  stone  or  in- 
spissated bile.  Largely  to  depend  upon  it  as  now  developed, 
would  be  to  step  back  twelve  years  in  the  advance  of  gall-bladder 
and  gall-duct  surgery  and  diagnosis."  In  this  connection  it  may 
be  stated  that  of  the  gall-bladders  operated  upon  at  this  Clinic, 
30  to  35  per  cent,  contain  no  stones. 

Factors  affecting  the  demonstrability  of  gall-stones  include 
their  composition,  size,  number,  and  situation,  their  enveloping 
medium,  the  amount  of  obscuration  by  liver-tissue,  the  thickness 
of  the  patient,  the  thoroughness  of  his  preparation  and  the 
roentgenographic  technic. 

Pure  cholesterin  stones  have  slight  density  and  are  most 
difficult  to  show.  The  mixed  type  of  stones,  containing  choles- 
terin, bilirubin  and  calcium  salts,  are  most  common,  and  their 
density  is  proportionate  to  the  amount  of  contained  lime. 
Stones  made  up  almost  wholly  of  lime  salts  cast  the  deepest 
shadow,  but  these  are  relatively  rare,  comprising  probably  less 
than  1  per  cent,  of  the  total.  Large  stones,  even  though  poor  in 
calcium,  and  numerous  small  stones  massed  together  may  some- 
times be  shown  (Fig.  292) .  ~^ 

Bile  has  considerable  absorptive  power  for  the  rays,  and 
stones  immersed  in  this  medium  are  less  plain  in  proportion  to 
the  amount  of  bile.  It  is  perhaps  for  this  reason  that  stones  in 
the  cystic  or  common  duct  can  be  shown  more  readily,  as  is 
claimed,  than  those  in  the  gall-bladder  (Figs.  293  and  294).  In 
occasional  instances,  stones  in  the  gall-bladder  are  less  opaque 


GALL-STONES 


353 


than  the  surrounding  bile,  as  can  be  easily  shown  by  raying 
gall-bladders  which  contain  bile  and  stones,  after  surgical  re- 
moval (Fig.  295). 


lEHIQ 


Fig.  292. — Gall-stones  from  forty-eight  different  cases.  After  removal  the  stones 
were  put  into  small  pasteboard  boxes  and  roentgenographed  on  a  single  plate.  Note  the 
variability  of  size  and  density  of  the  shadows. 

The  density  of  the  liver-tissue,  by  obscuring  the  shadows  of 
stones,  is  a  serious  obstacle  to  their  detection,  and  numerous 
technics  have  been  devised  to  minimize  this  difficulty.     The 

23 


354  DISEASES    OF   THE    GALL-BLADDER   AND    LIVER 


Fig.  293.— a,  Stone  in  the  cystic  duct,     b,  Stone  in  the  long  pendulous  gall-bladder. 


Fig.  294. — Arrow  indicates  stone  in  the  common  duct. 


GALL-STONES  355 

thick  belly  of  corpulent  individuals,  who  frequently  have  gall- 
stones, is  an  added  hindrance  to  satisfactory  roentgenography. 
Technic. — While  in  rare  instances  the  shadows  of  large  cal- 
careous stones  can  be  seen  fluoroscopically,  plating  is  almost 
invariably  necessary  for  diagnosis.  As  indicated  in  the  fore- 
going citations,  roentgenographic  methods  differ.  Notwith- 
standing the  objection  quoted,  a  preliminary  clearing  out  of  the 
intestinal  canal  has  obvious  advantages.     Hence,  we  prefer  to 


Fig.  295. — Stones  in  the  gall-bladder.  The  roentgenogram  was,  made  after  the  gall- 
bladder had  been  removed  intact,  with  its  contained  stones  and  bile.  The  stones  are 
seen  as  dark  areas  lying  in  the  more  opaque  bile. 

have  the  patient  purge  himself  with  castor  oil  or  a  saline,  and 
fast  prior  to  the  examination.  It  is  our  custom  also  to  make 
this  examination  before  giving  an  opaque  meal,  the  shadows  of 
which  may  be  confusing,  although  we  have  incidentally  noted 
stone-shadows  after  the  barium  meal  had  been  given.  For 
plating,  various  positions  have  been  advised.  To  avoid  as  much 
as  possible  of  the  liver-shadow,  many  operators  lay  the  patient 
on  the  belly  and  direct  the  rays  through  the  gall-bladder  region 


356  DISEASES    OF   THE    GALL-BLADDER  AND    LWER 

obliquely  downward,  using  compression.  The  tube  placed 
vertically  over  the  plate  often  gives  equally  satisfactory  defini- 
tion. After  trying  numerous  different  angles  we  are  unable  to 
say  that  any  one  position  is  superior.  The  cone  undoubtedly 
gives  sharper  images.  Plates  should  be  made  during  suspended 
respiration  to  avoid  blurring  by  movement.  The  intensifying 
screen  also  helps  to  avert  this  by  shortening  the  exposure  time. 
On  the  other  hand,  the  intensifying  screen,  if  it  happens  to  be 
imperfect,  increases  the  danger  of  artifacts.  Customarily,  we 
make  a  few  unscreened  plates  also.  It  is  essential  that  the  tube 
be  of  moderate  vacuum,  inclining  to  softness  rather  than  hard- 
ness, and  overexposure  should  be  shunned.  We  have  occasion- 
ally inflated  the  colon  before  making  plates,  employing  for  the 
purpose  a  Politzer  bag  and  rectal  tube.  In  a  few  instances  the 
air-distended  hepatic  flexure  made  a  background  upon  which  the 
stone-shadows  stood  out  distinctly.  Probably  the  most  im- 
portant technical  recommendation  is  the  making  of  many  plates, 
varying  the  penetration  and  exposure-time,  for  it  is  notorious 
that  of  two  plates  of  apparently  equal  excellence,  one  may  show 
distinct  shadows  while  the  other  reveals  no  trace  of  them. 

The  opinion  that  if  shadows  of  stones  appear  they  will  usually 
be  found  between  the  eleventh  and  twelfth  ribs  or  slightly 
below  the  twelfth  is  erroneous.  In  the  majority  of  our  cases,  the 
stone-shadows  were  situated  much  lower,  ranging  from  the  level 
of  the  first  lumbar  vertebra  to  that  of  the  fourth  lumbar.  The 
configuration  of  the  costal  arch  varies  to  an  extent  that  the  ribs 
are  not  always  satisfactory  landmarks.  Besides,  the  gall- 
bladder itself  is  subject  to  some  variation  of  position.  The 
examiner  should,  therefore,  not  limit  his  search  for  stone- 
shadows  to  the  classic  field,  but  should  carefully  scan  the  entire 
right  abdominal  region  and  even  as  low  as  the  iliac  crest.  The 
most  characteristic  appearance  is  that  produced  by  the  grouped 
shadows  of  multiple  stones,  showing  like  a  bunch  of  grapes. 
Occasionally  the  facets  can  be  distinguished.  These  shadows 
are  not  usually  as  dense  as  those  of  the  large  olive-shaped  stones, 
which  are  often  single,  and  sometimes  show  concentric  laminae. 


TECHNIC  357 

Shadows  of  gall-stones  must  be  differentiated  from  those  of 
renal  calculi.  The  latter  are  usually  branched  or  irregular  and 
of  greater  density  than  gall-stones,  thus  casting  a  more  intense 
shadow  (Fig.  296).  Differentiation  can  be  made  by  plates  show- 
ing good  detail  which  outline  the  kidney  by  stereo-roentgeno- 
grams,  and  by  pyelography  after  the  injection  of  collargol  (Figs. 
297,  298  and  299).  Plates  made  from  back  to  front  show  gall- 
stones with  better  definition  than  renal  calculi,  while  plates  made 


Fig.  296. — Comparison  of  renal  and  biliary  calculi      The  kidney  stones  are  seen  above 

the  line. 

from  front  to  back  bring  out  the  kidney-stones  more  plainly. 
It  is  commonly  stated  that  gall-stones  lie  further  from  the 
vertebrae  than  do  renal  calculi,  but  in  both  instances  the  rela- 
tion of  their  shadows  to  the  spine  is  variable.  Indeed,  gall- 
stones may  lie  so  near  the  vertebral  column  (Fig.  300)  that  slight 
rotation  of  the  patient  may  obliterate  their  shadow  in  that  of  the 
vertebrae.  Calcified  lymph  nodes  may  be  mistaken  for  gall- 
stones, but  the  former  seldom  show  in  clusters,  and  are  often 
irregularly  shaped  (Fig.  301).     Deposits  of  lime  salts  in  the  ribs 


358 


DISEASES   OF   THE    GALL-BLADDER   AND    LIVER 


Fig.  297. — Renal  calculus  excluded  by  pyelogram.     The  annular  shadow  of  the 
gall-stone  is  pointed  out  bj'  the  arrows. 


Fig.  298. — Renal  calculi  excluded  by  pyelogram,  p.     Kidnej-  outline,  fc, 
Gall-stones  at  s. 


TECHNTC 


359 


Fig.  299. — Large,  single  gall-stone  at  i.     Injected  kidney  at  p. 


Fig.  300. — Cluster   of   faceted   gall-stones,  indicated    by   arrow,    very   near  vertebral 

column. 


360 


DISEASES    OF   THE    GALL-BLADDER   AND    LWER 


generally  show  irregular  streaking,  and  are  directly  in  line  with 
the  rib-shadow.  Fecaliths  and  fecal  matter  in  the  intestine  may 
exceptionally  produce  shadows  somewhat  resembling  those  of 
gall-stones,  and  for  this  reason  the  bowel  should  be  thoroughly 
evacuated  beforehand.  In  addition  to  these  sources  of  error, 
inexphcable  shadows  (Fig.  301)  are  often  seen  which  by  an 
active  exercise  of  the  observer's  imagination  can  be  interpreted 


Fig.  301. — Calcified  Ij-mph  glands  indicated  by  arrows. 


as  being  due  to  gall-stones.  In  everj'  doubtful  case  a  reexami- 
nation should  be  made.  At^i^ical  and  uncertain  shadows 
should  never  be  considered  too  seriously  whether  clinically  sub- 
stantiated or  not. 

Case  133,413,  female,  aged  47  years.  Twelve-year  history.  Full- 
ness and  heaviness  after  meals  relieved  bj^  vomiting,  usually  induced, 
rarely  spontaneous.  Always  some  soreness  in  region  of  liver  and  as- 
cending colon.  ]\Iuch  gas.  Regurgitates  bitter  fluid.  Apples  and 
fats  cause  distress.  Never  definite  colic;  never  jaundiced.  Total 
acidity  10,  all  combined.  Roentgen  findings:  Shadows  of  multiple 
small  stones.     The  low  position  of  these  shadows,  in  the  ilio-sacro- 


TECHNIC 


361 


Fig.  301A. — Shadow  in  the  gall-bladder  region.  Because  of  its  atypical  character  a 
pyelogram  was  made  to  exclude  a  renal  calculus.  This  being  excluded,  the  ^shadow  was 
thought  to  be  a  gall-stone.  At  operation  it  proved  to  be  a  desmoid  tumor  of  the  right 
rectus  abdominal  muscle. 


Fig.  302. — Case  133,413.     The  arrow  points  to  the  stone  shadows. 


362 


DISEASES    OF    THE    GALL-BLADDER    AND    LIVER 


lumbar  angle,  as  shown  in  the  roentgenogram,  Fig.  302,  is  noteworthy. 
The  case  illustrates  the  variable  position  of  the  gall-bladder  and  the 
necessity  of  searching  the  entire  right  abdomen  for  shadows  in  sus- 
pected cases.  Findings  at  operation:  Cholecystitis  with  multiple 
small  stones  (Cholecystectomy).  Pathologist's  report:  Chronic  ca- 
tarrhal cholecystitis.     Cholelithiasis. 

Case  140,266,  female,  aged  34  years.  History  of  gastric  distress 
and  vomiting  by  spells,  since  childhood.  Seven  years  ago,  during 
about  two  months,  she  had  attacks  of  severe  pain  at  the  right  costal 
margin,  and  beneath  shoulder-blade,  lasting  one  or  two  days.     For  a 


Fig.  303. — Case  140,266.     Shadow  of  a  single  gall-stbne  marked  by  the  arrow. 


year  past  she  has  been  having  epigastric  pain  a  half  to  two  hours  after 
meals,  with  occasional  vomiting.  Much  epigastric  soreness.  Total 
acidity  74;  free  64;  combined  10;  filtrate  500  c.c.  Roentgen  findings: 
Shadow  of  a  single  stone  slightly  above  and  to  the  right  of  duodenal 
bulb  (Fig.  303).  This  shadow  was  visible  also  during  the  roentgeno- 
scopic  examination,  its  density  being  due  to  the  fact  that  the  stone 
contained  considerable  calcium.  Findings  at  operation:  Gall-stone 
obstructing  neck  of  cystic  duct  (Cholecystectomy).  Pathologist's 
report:  Edematous  chronic  cholecystitis  (old  empyema  with  stone  in 
cystic  duct). 


EEPORT    OF    CASES  363 

Case  86,771  (Roentgen-ray  number  22,624),  female,  aged  21  years. 
The  patient  states  that  she  has  had  pain  and  tenderness  in  the  right 
abdomen  for  a  number  of  years.  An  appendectomy  three  years  ago 
gave  rehef  for  a  few  months.  A  year  and  a  half  ago  she  began  vomit- 
ing, and  for  seven  months  she  has  vomited  after  almost  every  meal. 
She  first  has  a  sense  of  uneasiness  and  epigastric  fullness  after  the 
meal;  then  vomits  in  a  half  to  one  hour.  The  gastric  contents  are 
ejected  without  nausea.  Every  few  days  at  irregular  times  the  patient 
has  rather  sharp  pains  at  the  right  costal  margin,  radiating  to  the  back, 
relieved  by  heat  and  by  vomiting.  She  has  never  required  morphia 
for  the  pain,  and  has  never  been  jaundiced.  Total  acidity  66,  all 
combined.  Roentgen  findings:  Multiple,  small,  characteristic,  annu- 
lar shadows  of  gall-stones  (Fig.  304).  These  were  first  discovered 
accidentally  in  making  a  roentgenogram  of  a  duodenal  tube  in  situ. 
Their  visibility  and  the  number  shown  were  increased  by  inflating  the 
colon.  Findings  at  operation:  Numerous  stones  in  gall-bladder. 
Gall-bladder,  liver,  duodenum  and  pyloric  end  of  stomach  adherent 
in  one  mass  with  transverse  colon  and  anterior  abdominal  wall 
(Cholecystectomy) . 

Case  152,564,  female,  aged  51  years.  For  fifteen  years  she  has  had 
attacks  of  pain  in  right  hypochondrium,  lasting  two  or  three  hours. 
At  present  she  complains  of  constant  pain  in  the  right  abdominal  area 
unless  she  takes  medicine.  Icterus  now  and  in  former  attacks.  Total 
acidity  72;  free  60;  combined  12.  Roentgen  findings:  Shadows  of  two 
large  gall-stones  (Fig.  305).  Findings  at  operation:  Two  large  stones 
in  gall-bladder  (Cholecystectomy).  Pathologist's  report:  Chronic 
catarrhal  cholecystitis  with  partial  destruction  of  mucosa.  Chole- 
lithiasis. 

DISEASES  OF  THE  GALL-BLADDER 

In  lesions  of  the  gall-bladder  without  discoverable  stones  the 
roentgen-ray  can  only  exceptionally  furnish  decisive  evidence. 
The  gall-bladder  itself,  when  it  contains  inspissated  bile,  or  its 
walls  are  thickened  or  calcified,  occasionally  casts  a  shadow  if 
the  patient  is  not  too  thick  and  other  circumstances  are  favor- 
able (Fig.  310).  Otherwise,  the  roentgen  manifestations  of 
cholecystitis  are  quite  insufficient  to  support  a  diagnosis  alone, 
although  they  may  have  some  indirect  and  contributory  value. 
Most  of  these  indirect  signs  are  obtained  in  the  course  of  a 


364  DISEASES    OF    THE    GALL-BLADDER    AND    LIVER 


Fig.  304. — Case  86,771.     Stone  shadows  marked  by  arrow. 


Fig.  305. — Case  152,564.     Arrow  marks  shadows  of  stones. 


DISEASES    OF    THE    GALL-BLADDER 


365 


routine  examination  of  the  digestive  tract,   and  include  the 
following : 

1.  Gastric  spasm. 

2.  Six-hour  residue  in  the  stomach  or  duodenum. 

3.  Fixation  of  the  pyloric  end  of  the  stomach,  duodenum  or 
hepatic  flexure. 


Fig.  306. 


Fig.   30: 


Fig.  3U6.  Fig.  309. 

Figs.  306,  307,  308,  309. — Illustrative  cases  of  gall-stones. 


4.  Drawing  of  the  stomach  to  the  right  by  adhesions,  or 
displacement  to  the  left  by  an  inflammatory  mass  about  the 
gall-bladder. 

5.  Increased  gastric  peristalsis. 

6.  Demonstration  of  Riedel's  lobe  of  the  liver. 

7.  Localization  of  a  tender  point  over  the  gall-bladder  area. 


366  DISEASES    OF    THE    GALL-BLADDER    AND    LWER 


Fig.  310.— Lime-encrusted  gall-bladder.     Probe  passed  into  gall-bladder  through 

discharging  sinus. 


Fig.  311. — Gastrospasm,  localized  to  pyloric  end  of  stomach,  a.  This  type  of 
gastrospasm  is  frequently  associated  with  disease  of  the  gall-bladder.  In  this  instance 
cholecystitis  was  found  at  operation. 


DISEASES    OF    THE    GALL-BLADDER  367 

8.  Demonstration  of  an  organically  normal  stomach  and 
duodenum,  and  thus  excluding  them  as  probable  causes  of  the 
symptoms. 

As  mentioned  elsewhere  (see  "Gastrospasm"),  spasms  of  the 
gastric  musculature  occur  frequently  in  association  with  chole- 
lithiasis, cholecystitis  and  pericholecystitis — so  frequently  that 
the  gall-bladder  should  be  suspected  first  of  all  whenever  spastic 


Fig.  312. — Spasm  of  the  pars  pylorica,  a.     Disease  of  the  gall-bladder  the  only  lesion 

found  at  operation. 

eccentricities  of  the  stomach  are  noted  (Fig.  311).  The  spas- 
modic manifestations  in  the  stomach  may  be  slight  or  extensive, 
ranging  from  a  transient  incisura  or  a  temporary  hour-glass 
to  a  regional  spasm  with  considerable  deformity.  An  especially 
striking  type  of  the  latter  is  that  in  which  the  entire  pars  p^^lorica 
is  contracted  to  a  narrow,  stiffened,  sometimes  palpable,  tube 
(Fig.  312). 

A  six-hour  residue  in  the  stomach  or  duodenum  may  occur 
as  a  result  of  pericholecystic  adhesion-bands  constricting  the 
pylorus  or  duodenum.     Again,  a  gastric  residue  may  be  found. 


368  DISEASES    OF    THE    GALL-BLADDER    AND    LWER 

although  rarely,  in  association  with  cholecystitis  but  without 
any  organic  obstruction. 

The  pyloric  end  of  the  stomach  may  be  fixed  and  its  contour 
roughened  by  adhesions.  The  duodenum,  especially  the  bulb, 
may  likewise  be  deformed  or  stenosed.  Adhesions  may  fix 
the  hepatic  flexure  of  the  colon  to  the  pylorus  or  duodenum  so 
that  they  cannot  be  separated  by  manipulation. 

Adhesions  about  the  gall-bladder  may,  though  rarely,  draw 
the., stomach  to  the  right,  and  if  they  obstruct  the  duodenum, 


Fig.   313. — Indentation  of  pjdoric  end  of  stomach  at  d  by  gall-bladder. 

the  pars  pylorica  may  be  somewhat  expanded  and  bulbous. 
On  the  other  hand,  a  distended  gall-bladder,  or  an  inflammatory 
mass  about  it,  may  indent  the  pars  pylorica  or  bulb  (Fig.  313), 
or  displace  it  to  the  left.  The  mass  may  be  palpable  and  either 
mobile  or  adherent  to  the  abdominal  wall.  Exceptionally,  such 
m^asses  may  be  carcinomatous.  In  one  instance  of  cancer  of 
the  gall-bladder  which  we  observed,  perforation  into  the  duo- 
denum had  occurred  and  the  communication  was  shown  by  the 
barium  meal  (Fig.  314). 


DISEASES    OF    THE    GALL-BLADDER 


369 


Fig.  314. — Carcinoma  pyloric  end  of  stomach;  communication  between  duodenum 
and  gall-bladder.  Barium  in  gall-bladder,  G.  B.  Arrows  point  to  barium  in  hepatic 
ducts. 


Fig.  315. — Reconstruction  of  common  duct  (Sullivan  method), 
in  common  duct,  partly  in  duodenum. 
24 


Rubber  tube,  t,  partly 


370      DISEASES  OF  THE  GALL-BLADDER  AND  LIVER 

Overactive  gastric  peristalsis,  with  an  increase  in  the  number 
of  waves,  is  not  infrequently  seen,  with  or  without  duodenal  or 
pyloric  obstruction  by  adhesions.  Though  more  numerous,  the 
waves  are  not  deepened  as  a  rule,  and  are  usually  more  marked 
on  the  greater  curvature  than  on  the  lesser. 

Case^  considers  the  presence  of  a  Riedel's  lobe  of  the  liver, 
which  may  be  demonstrable  after  inflation  of  the  colon,  as  a 
valuable  sign  of  cholecystitis. 

The  localization  of  a  pressure-tender  point,  outside  the 
duodenal  shadow,  is  of  questionable  worth,  though  occasionally 
mentioned. 

The  most  common  lesions  giving  rise  to  symptoms  which 
are  often  confusingly  similar  are  gastric  ulcer,  duodenal  ulcer, 
cholecystitis  and  appendicitis.  When  the  roentgen  findings 
negate  the  presence  of  a  peptic  ulcer,  the  field  of  reasonable 
consideration  is  narrowed  to  the  gall-bladder  and  appendix. 
Certainly,  negative  roentgen  findings  do  not  exclude  the  pos- 
sibility of  peptic  ulcer,  but  they  do  exclude  its  probability,  and 
the  diagnostician  usually  welcomes  this  aid. 

THE  LIVER 

Although  a  roentgenologic  examination  of  the  liver  is  not 
often  requested  by  clinicians,  definite  and  useful  information 
can  sometimes  be  elicited  by  this  means.  The  upper  border 
of  the  hepatic  shadow,  coinciding  with  the  diaphragm,  can  be 
readily  made  out.  Its  lower  border  ordinarily  shades  off  some- 
what indistinctly,  but  by  inflating  the  stomach  and  colon  it 
can  be  shown  more  or  less  plainly.  Thus,  it  is  possible  to 
determine  certain  abnormalities  of  size,  form  and  position. 

An  increase  of  the  Uver- volume,  with  general  and  symmetrical 
enlargement  of  its  shadow,  may  be  due  either  to  hyperemia,  or 
to  an  actual  hypertrophy  resulting  from  various  causes,  includ- 
ing amyloid  degeneration,  cancer  and  syphilis.  The  diminished 
shadow  of  an  atrophic  liver  can  be  distinguished  when  the  com- 
monly accompanying  ascites  has  been  relieved  by  paracentesis. 

Local   deformities   of   the   hepatic    contour   are   sometimes 


THE    LIVER  371 

visible  as  a  result  of  cancer,  syphilis,  abscess,  or  cyst.  In 
cancer,  nodulation  along  the  diaphragmatic  border  is  occasion- 
ally marked.  Subdiaphragmatic  abscess  may  be  manifested 
by  elevation  and  fixation  of  the  diaphragm,  with  clear  lung  area 
above  and  normal  costo-phrenic  angle  (Fig.  316).  In  some  cases 
there  may  be  a  visible  collection  of  gas  and  fluid  below  the 
diaphragm.  The  liver,  being  plastic,  may  sometimes  mold 
itself  into  the  distortions  of  the  diaphragm  occasionally  pro- 


FiG.  316. — Subdiaphragmatic  abscess.     Abscess  area,  a;  diaphragm  high  and  fixed. 

duced  by  pleural  adhesions.  Jaugeas^°  reports  two  cases  in 
which  hydatid  cysts,  peripherally  situated,  gave  rise  to  smoothly 
contoured  shadows  resembling  those  of  abscesses.  Since  it 
possesses  a  degree  of  mobility,  the  liver  is  subject  to  displace- 
ment both  by  physiologic  and  pathologic  causes.  Distention 
of  the  stomach  and  intestine  with  food  or  gas  may  displace  the 
liver  upward,  or  laterally  to  some  extent.  Ascites  and  large 
intraabdominal  tumors  also  may  elevate  the  liver,  or  it  may  be 
depressed  by  intrathoracic  conditions — emphysema,  pleural 
effusion.     Transposition  of  the  liver  occurs,  of  course,  in  the 


372  DISEASES    OF    THE    GALL-BLADDER    AXD    LR^ER 

rare  cases  of  situs  inversus.  Kormally  in  contact  with  the 
diaphragm,  the  hver  may  be  ptosed.  in  which  case  the  separation 
of  the  upper  hepatic  border  from  the  diaphragm  becomes  ap- 
parent (Fig.  317).  In  marked  hepatoptosis  the  transverse 
colon  has  been  seen  between  the  liver  and  the  diaphragm. 
The  normal  rise  and  fall  of  the  liver  with  expiration  and  inspira- 


FiG.  317. — Slight  ptosis  of  liver,  I.     Diaphragm,  d.     The  right  lobe  of  the  liver  is  well 
outlined  because  of  the  clear  lung  area  above  and  the  gas  in  the  colon  below. 

tion  is  sometimes  evidently  diminished  or  absent  when  fixation 
has  resulted  from  inflammatory  processes,  either  in  the  chest  or 
upper  abdomen. 

REFERENCES 

1.  Beck,  Gael:  '"  On  the  Detection  of  Calculi  in  the  Liver  and  Gall- 

bladder."    Xew  York  Med.  Jour.,  1900,  Ixxi,  73-77. 

2.  Pfahleb,  G.  E. :  "The  Roentgen-rays  in  the  Diagnosis  of  Gall- 

stones and  Cholecystitis."     Jour.  A.  M.  A.,  1914,  Ixii,  1304- 
1306. 

3.  Rl"baschow,    S.:  "Zur    Rontgenodiagnostik    der    Gallensteine." 

Fortschr.  a.d.  Geb.  d.  Roentgenstrahlen,  1914,  xxi,  533-36.. 


REFERENCES  373 

4.  Case,  J.  T.:  "Roentgenoscopy  of  the  Liver  and  Biliary  Passages, 

with  Special  Reference  to  Gall-stones."     Jour.  A.  M.  A.,  1913, 
Ixi,  920-24. 

5.  Cole,  L.  G.:  "The  Roentgenographic  Diagnosis  of  Gall-stones 

and  Cholecystitis."     Surg.,  Gynec.  &  Obstet.,  1914,  xviii,  218-27. 

Cole,  L.  G.  and  George,  A.  W. :  "The  Roentgen  Diagnosis  of 

Gall-stones  by  Improved  Methods."     Bos.  Med.  &  Surg.  Jour., 

1915,  clxxii,  326-330. 

6.  George,  A.  W.  and  Leonard,  R.  D.:  "The  Roentgen  Diagnosis 

of   Surgical  Lesions   of   the   Gastro-intestinal   Tract."     1915, 
Colonial  Medical  Press,  Boston,  p.  140. 

7.  Caldwell,  E.  W. :  "The  Safe  Interpretation  of  Roentgenograms 

of  the  Gall-bladder  Region."     Amer.  Jour.  Roent.,  1915,  ii,  816- 
819. 

8.  Mayo,  C.  H.:  "Gall-bladder  Diseases."     New  York  Med.  Jour., 

1916,  ciii,  433-36. 

9.  Case,  J.  T.:  "The  X-ray  Examination  of  the  Liver  and  Gall- 

bladder."    Arch.  Roentgen  Ray,  1913,  xviii,  135-39. 
10.  Jaugeas:  "Radioscopic  Examination  of  the  Liver."     Arch.  Roent- 
gen Ray,  1913,  xviii,  48-52. 


CHAPTER  XVIII 

THE  SMALL  INTESTINE 

In  most  instances  the  small  intestine  can  be  studied  as  a 
supplement  to  and  during  the  examination  of  the  stomach. 
Thus  its  disposal  of  the  six-hour  meal,  some  of  which  will  usually 
remain  in  the  lower  ileum,  can  be  observed,  while  the  duodenum 
and  upper  jejunum  will  ordinarily  be  visuaUzed  soon  after  in- 
gestion of  the  barium-water  and  barium-pap.  Visualization 
can  often  be  assisted  by  manual  expression  of  the  gastric  con- 
tents. Occasionally,  but  not  often,  there  is  some  advantage  in 
tracing  the  progress  of  a  single  meal  through  the  intestine  by 
examination  at  frequent  intervals.  The  standing  position  is 
commonly  employed  for  screening,  but  the  recumbent  position 
may  be  of  service  in  investigating  the  lower  coils  of  the  ileum 
which  often  lie  behind  the  pubic  arch  when  the  patient  is  stand- 
ing and  are  thus  difficult  to  manipulate.  With  the  patient  in 
the  right  lateral  decubitus  or  in  the  prone  position  the  duodenum 
is  occasionally  more  completely  filled  and  its  condition  can  be 
more  accurately  determined. 

THE    NORMAL    SMALL    INTESTINE 

The  Duodenum. — Beginning  at  the  pyloric  hiatus,  sweeping 
upward  or  outward,  then  to  the  right  and  downward,  around 
the  head  of  the  pancreas,  the  duodenum  presents  roentgeno- 
logic appearances  which  may  vary  considerably  within  normal 
bounds.  Somewhat  resembUng  a  horseshoe  in  its  course,  the 
duodenum  is  divided  by  some  anatomists  into  three  portions, 
by  others  into  four. 

The  first  segment,  or  pars  superior,  includes  the  bulb  (cap) 
which  is  the  most  expanded  portion  of  the  duodenum  and  is  of 
especial  interest.     When  filled  with  barium  it  is  seen  in  the 

374 


THE    DUODENUM 


375 


anterior  view  as  a  smoothly  contoured,  more  or  less  conical, 
or  beehive-shaped,  chamber,  with  its  base  at  the  pyloric  ring 
(Figs.   318  and  319),     The  direction  of  its  long  axis  depends 


Fig.  319. — Normal  duode- 
nal bulb,  b. 


Fig.  318. — Normal  duodenal  bulb,  b. 


Fig.  320. — Entire  duodenum  well 
visualized. 


Fig.  321. — Serrated 'outline  of  upper 
jejunum,  j. 


largely  upon  the  form  of  the  stomach,  whether  steer-horn  or 
fish-hook.  With  a  pronounced  steer-horn  type  of  stomach  the 
long  axis  of  the  bulb  is  often  quite  horizontal.     With  the  fish- 


376  THE    SMALL    INTESTINE 

hook  type  of  stomach  the  bulb  is  usually  seated  vertically  over 
the  p3dorus.  Between  these  types  various  angles  of  obliquity 
upward  and  to  the  right  are  often  seen.  A  fish-hook  stomach 
Ijdng  well  to  the  right  may  also  carry  the  base  of  the  bulb  with 
it  and  thus  inchne  the  long  axis  of  the  bulb  upward  and  to  the 
left. 

The  conical  peak  of  the  bulb  as  usually  seen  in  the  ante- 
rior view  suggests  a  marked  narrowing  of  the  duodenum  at 
that  point,  but  this  narrowing  is  only  apparent  and  is  due  to 
the  course  of  the  duodenum  which  turns  backward  from  the 
bulb,  then  outward  and  downward.  The  fact  that  the  duo- 
denum is  not  narrowed  can  be  shown  by  an  oblique  or  lateral 
view. 

The  shadow  of  the  barium-filled  bulb  under  normal  condi- 
tions is  more  dense  than  the  remainder  of  the  duodenal  shadow, 
due  in  part  to  the  more  anterior  situation  of  the  former,  its 
greater  size  and  the  tendency  of  the  opaque  meal  to  tarry  here 
momentarily'.  Its  form  is  fairly  symmetrical,  and  its  contour 
is  smooth,  as  it  contains  no  valvulse  conniventes.  Its  size 
varies  markedly;  a  bulb  the  size  of  a  chocolate  cream  and  one 
three  or  four  times  as  large  may  each  be  normal.  The  pro- 
portion of  length  to  breadth  also  varies;  with  an  elongated, 
low-lying  stomach  the  bulb  may  have  the  length  and  breadth 
of  a  finger;  ordinarily  the  disproportion  is  not  so  great.  Com- 
monly, the  base  of  the  bulb  shows  as  a  straight  line,  but  if  the 
bulb  be  large  the  base  may  curve  slightly  downward  peripherally. 

By  reason  of  the  rapid  transit  of  its  contents,  the  second  or 
descending  (vertical)  portion  of  the  duodenum  is  not  often 
well  visuahzed.  As  seen  from  in  front  it  may  descend  quite 
vertically  or  curving  with  a  right  convexity,  and  thus  its 
apparent  angle  with  the  superior  portion  varies  in  acuteness. 
With  a  stomach  displaced  to  the  right,  the  descending  portion 
of  the  duodenum  may  be  hidden  behind  the  bulb  and  antrum. 
When  seen,  its  shadow  is  far  less  dense  and  homogeneous  than 
that  of  the  bulb,  and  the  barium  passing  through  it  in  small 
quantities  makes  it  appear  narrower  than  it  is. 


THE    JEJUNUM  377 

The  third  (transverse)  portion  of  the  duodenum  extends 
more  or  less  horizontally  from  the  vertical  portion  toward  the 
spine,  then  curves  upward,  the  latter  segment  being  sometimes 
described  as  a  fourth  portion.  The  suspensory  ligament  of 
Treitz  marks  its  termination  and  the  beginning  of  the  jejunum, 
the  junction  being  sometimes  visible  as  a  flexure  at  that  point. 
The  valvulse  conniventes,  rudimentary  in  the  lower  half  of  the 
first  portion  and  in  the  second  portion,  are  well  marked  in  the 
third  portion,  so  that  the  shadowed  barium  in  the  latter  shows 
a  serrated  appearance.  The  aspect  of  the  normal  duodenum 
is  shown  in  Fig.  320.  As  to  mobility,  the  bulb  can  be  shifted 
about  to  some  extent  by  palpatory  manoeuvers,  but  the  re- 
mainder of  the  duodenum  is  fixed  and  not  responsive  to 
manipulation. 

Peristaltic  movements  in  the  duodenum  are  difficult  to 
detect.  Under  ordinary  circumstances  the  bulb  is  seen  to  fill, 
then  suddenly  to  overflow  into  the  descending  and  transverse 
portions,  through  which  the  barium  races  quickly,  and  the 
entire  duodenum  is  more  or  less  completely  evacuated,  seemingly 
as  though  by  syphonage,  rather  than  by  an  active  expulsive 
contraction  of  the  duodenum  itself.  However,  competent 
observers,  including  Holzknecht,  have  noted  actual  peristalsis, 
rhythmical  in  character,  at  minute-long  intervals. 

The  Jejunum. — Beginning  at  the  duodenojejunal  juncture, 
the  first  segment  of  the  jejunum  courses  either  directly  toward 
the  left  hypochondrium  or  downward  and  to  the  left.  The  first 
loops  are  often  seen  soon  after  ingestion  of  the  barium-water, 
especially  if  the  exit  through  the  pylorus  is  free.  Issuing  from 
the  duodenum,  a  barium-mass  is  sometimes  observed  to  dart 
suddenly  across  the  abdomen  to  the  left,  where  it  is  speedily 
broken  up  and  diffused  through  that  portion  of  the  intestine, 
making  its  subsequent  course  untraceable.  The  barium- 
shadowed  jejunum  shows  as  an  indefinite  grayish  cloud,  with 
here  and  there  the  feathery  effect  of  the  valvulse  conniventes 
(Fig.  321). 

The  movements  of  the  small  intestine  have  been  studied  in 


378  THE    SMALL    INTESTINE 

animals  by  Cannon,  and  in  man  by  Hertz,  Beclere  and  others. 
In  cats  Cannon^  has  observed  what  he  calls  ''rhythmic  segmen- 
tation," and  two  varieties  of  peristaltic  movement.  Rhythmic 
segmentation  consists  in  a  sudden  division  of  a  long  food-mass 
into  many  little  segments  of  nearly  equal  size;  then  these  seg- 
ments are  again  suddenly  divided,  and  the  neighboring  halves 
unite  to  make  new  segments,  and  so  on.  From  the  beginning  to 
the  end  of  the  period  of  segmentation,  the  food  changes  its  posi- 
tion in  the  abdomen  or  intestine  to  only  a  slight  extent.  The 
rapidity  of  the  changes  is  remarkable,  the  rate  of  division  being 
twenty-eight  or  thirty  times  in  a  minute.  The  peristaltic  wave 
is  seen  in  two  forms.  The  first  merely  transports  nutriment  from 
one  region  to  another  near  by.  Its  rate  is  slow,  being  variously 
estimated  as  1  or  2  cm.  per  minute.  The  wave-contraction 
involves  4  or  5  cm.  of  the  intestine,  whereas  the  rhythmic 
segmenting  contraction  is  hardly  more  than  1  cm.  broad.  The 
other  form  of  peristaltic  wave,  the  peristaltic  rush,  is  swift,  and 
may  glide  rapidly  from  one  end  of  the  canal  to  the  other. 
Cannon  mentions  also  the  so-called  ''pendulum  movements" 
which  have  been  variously  described  by  different  observers, 
and  which  he  characterizes  as  a  gentle  swaying  movement  of 
the  coils  accompanying  the  rhythmic  contractions. 

In  man,  Hertz^  has  on  numerous  occasions  observed  well- 
marked  segmentation,  at  the  rate  of  ten  divisions  in  a  minute 
and  a  half.  The  shadow  of  the  cecum  began  to  appear,  on  an 
average,  at  four  and  three-eighths  hours;  hence,  he  computed 
the  rate  at  which  the  intestinal  contents  travel  as  about  1  inch 
per  minute. 

Faulhaber^  refers  to  the  roentgen-kinematographic  studies 
of  Kaestle  and  Brugel  as  showing  a  mixing  and  kneading 
movement  (segmentation)  and  a  propulsive  peristaltic 
m.ovement. 

Beclere  and  Meriel,^  as  well  as  others,  state  that  after  a  half 
hour  the  opaque  meal  is  seen  in  the  left  and  mid-abdomen.  After 
two  hours  it  predominates  in  the  middle  and  lower  abdomen. 
After  four  hours  it  occupies  only  a  portion  of  the  ileum  and  is 


THE    ILEUM  379 

already  manifest  in  the  cecum.  At  six  hours  only  a  little 
remains  in  the  terminal  ileum.  At  eight  hours  the  small  bowel 
is  completely  empty. 

The  Ileum. — In  the  ileum  the  valvulae  conniventes  gradu- 
ally disappear  distally  until  the  lower  segments  become  quite 
smooth.  These  latter  lie  in  the  lower  mid-abdomen  and  right 
iliac  fossa,  usually  contain  a  good  portion  of  the  meal  given  six 
hours  previously,  and  thus  can  be  studied  during  the  routine 
examination  of  the  stomach  (Fig.  322).  By  manipulation  and 
pressure,  the  coils,  which  are  often  massed  together,  can  be 


Fig.  322. — Terminal  ileum,  i,  as  seen  six  hours  after  giving  the  meal. 

separated  for  scrutiny,  except  in  enteroptotics  who  are  likely 
to  have  the  lower  ileum  well  down  behind  the  pubic  arch.  Here 
the  recumbent  position  may  make  palpation  effective.  The 
terminal  segment,  which  is  often  involved  in  pathologic  proc- 
esses, deserves  especial  attention.  In  entering  the  ileocolic 
juncture  it  lies  at  varying  angles  from  the  cecum.  Frequently 
it  rises  alongside  the  cecum  and  turns  abruptly  into  the  cecal 
notch;  in  other  instances,  the  last  3  or  4  inches  lie  at  a  right  angle 
to  the  long  axis  of  the  ascending  colon,  and  exceptionally  the 
terminal  segment  descends  to  its  junction  with  the  large  bowel. 
Normally,  as  seen  on  the  screen,  the  barium-filled  lower  coils 


380  THE    SMALL    INTESTINE 

of  the  ileum  appear  to  have  the  breadth  of  a  finger,  with  an 
unbroken  contour,  and  are  mobile  in  proportion  to  their  situa- 
tion and  the  relaxation  of  the  abdominal  wall.  Peristaltic 
movement,  with  waves  of  slight  depth  succeeding  each  other 
rapidly,  has  been  observed,  but  this  is  seldom  seen  during  an 
ordinary  examination. 

Motility  of  the  Small  Bowel.^ — An  important  factor  in  the 
motility  of  the  small  intestine  is  the  rate  of  gastric  evacuation. 
Other  elements  which  influence  it  are  the  character  and  quan- 
tity of  the  opaque  meal,  and  whether  or  not  the  patient  has  been 
subjected  to  purgation  and  fasting,  or  other  unusual  conditions. 
With  the  routine  previously  described  for  examination  of  the 
stomach,  which  includes  fasting,  and  with  average  gastric 
motility,  the  ''head"  of  the  six-hour  barium  meal  will  most  often 
be  in  the  ascending  colon  while  a  good  portion  will  still  be  in 
the  terminal  loops  of  the  ileum.  The  remainder  of  the  small 
intestine  will,  as  a  rule,  be  empty,  although  there  may  at  times 
be  a  few  scattered  remnants  in  the  upper  ileum. 

The  normal  limit  for  fairly  complete  evacuation  of  the  small 
bowel,  as  defined  by  roentgenologists  who  have  occupied  them- 
selves with  the  matter,  ranges  from  eight  to  fifteen  hours  after 
taking  the  meal.  These  figures  are  generally  based  upon  a 
meal  of  barium  or  bismuth  in  fluid  carbohydrate  mixtures, 
given  without  previous  purgation  or  subsequent  fasting. 
Further,  the  gastric  evacuation-time  should  be  taken  into 
account  in  drawing  conclusions. 

THE  ABNORMAL  SMALL  INTESTINE 

The  Duodenum. — Irregularities  of  the  duodenal  contour 
have  as  their  more  common  causes,  spasm  or  scar-contraction 
from  duodenal  ulcer  and  pericholecystic  adhesions.  Such 
irregularities  are  more  often  manifested  in  the  bulb,  and  are 
there  more  easily  discovered  (Fig.  323).  The  inner  contour 
of  the  bulb  is  sometimes  indented  by  pressure  against  the  spine. 
An  accessory  pocket,  resulting  from  perforating  ulcer,  may  show 
as  a  somewhat  spherical  adjunct  to  the  duodenal  lumen,  with 


THE    DUODENUM  381 

successive  layers  of  barium,  fluid  and  gas,  like  the  accessory 
pocket  of  perforating  gastric  ulcer,  but  a  localized  retention 
within  the  duodenum  itself  or  adjacent  small  bowel  may  exhibit 
similar  phenomena.  Duodenal  diverticula  show  as  a  pouch- 
like adjunct. 

Among  the  important  roentgenologic  findings  in  the  duo- 
denum are  the  evidences  of  obstruction,  the  usual  cause  of 
which  is  either  a  stenosing  duodenal  ulcer  or  the  adhesion  bands 
of  a  pericholecystitis.  These  evidences  include  localized  and 
permanent  narrowing  of  the  lumen,  with  dilatation  proximal 


Fig.  323. — Irregular  bulb,  6,  in  a  case  of  duodenal  ulcer. 

to  it,  and  delayed  motility.  Local  constriction  may  give  the 
duodenum  an  hour-glass  form.  As  mentioned  before,  in  the 
upright  sagittal  view  the  vertical  portion  of  the  duodenum 
often  appears  to  be  narrowed,  and  the  bulb  seems  to  have  a 
conical  termination;  neither  of  these  appearances  should  be 
mistaken  for  stenosis.  The  apparent  size  of  the  bulb,  as  well 
as  that  of  the  entire  duodenum,  depends  largely  upon  the 
balance  between  the  volume  of  inflow  through  the  pylorus  and 
the  rate  of  duodenal  evacuation,  so  that  what  seems  to  be  a 
narrow  duodenum  as  seen  with  the  patient  standing,  may  in 
fact  be  of  normal  caliber  and  appear  thus  when  the  patient  is 
placed  in  the  right  lateral  or  prone  position. 

Dilatation  proximal  to  the  point  of  stenosis  is  a  natural 


382  THE    SMALL    INTESTINE 

sequence  of  obstruction.  Dilatation  of  the  bulb  should  be 
judged  with  caution,  since  its  size  varies  widely  within  normal 
limits,  but  extreme  degrees  of  expansion  are  to  be  regarded  with 
suspicion. 

A  more  dependable  sign  of  obstruction  is  delayed  motihty. 
While  the  normal  duodenum  will,  as  a  rule,  evacuate  its  contents 
practically  as  fast  as  they  are  received,  usually  within  a  minute, 
the  barium  will  occasionally  lag  slightly  in  its  transit,  especially 
through  the  third  portion  and  this  is  not  necessarily  significant. 
But  with  organic  obstruction  there  is  sometimes  an  evident 
delay  at  the  point  of  stenosis,  and  a  manifest  and  persistent 
accumulation  of  the  barium  proximal  thereto.  In  extreme 
stenosis  a  residue  from  the  six-hour  meal  may  be  found  in  the 
duodenum.  Six-hour  retention  in  the  stomach  or  gastric  hyper- 
peristalsis  may  also  evidence  duodenal  obstruction,  a  combina- 
tion of  residue  and  hyperperistalsis  being  strongly  indicative 
of  ulcer  with  obstruction. 

The  observation  of  hyperperistalsis  of  the  duodenum  itself 
above  an  obstruction  has  been  recorded.  This  activity  has, 
in  some  instances,  been  described  as  extremely  marked  and  of  a 
'^writhing"  character.  Even  duodenal  antiperistalsis  has  been 
noted,  but  rarely. 

Kinking  at  the  duodenojejunal  juncture  as  a  feature  of 
intestinal  stasis  has  been  given  considerable  attention  by  a 
few  roentgenologists.  Acuteness  of  the  duodenojejunal  angle 
(kinking)  with  dilatation  and  hypomotility  of  the  duodenum 
are  regarded  by  them  as  important  evidences  of  stasis. 

Lessened  mobility  or  fixation  of  the  duodenal  bulb  may  be 
the  result  of  an  inflammatory  process  in  that  region,  but  immo- 
bility may  be  only  apparent  and  due  to  rigidity  of  the  abdomen. 

The  Abnormal  Jejunum. — Practically  the  sole  abnormahty 
of  the  jejunum  (and  upper  ileum)  showing  definite  roentgeno- 
logic signs  is  obstruction.  TSTien  the  obstruction  is  pronounced, 
these  signs  are  quite  decisive;  the  immense  dilatation  of  the 
small  bowel,  dehcately  ribbed  by  the  valvulse  conniventes,  the 
delayed  emptying,  accumulations  of  barium  at  different  points 


THE    ABNORMAL    ILEUM  383 

with  fluid  and  gas  above  them,  and  the  tendency  of  the  dilated 
loops  to  arrange  themselves  vertically,  are  characteristic.  Ob- 
struction high  up  in  the  jejunum  may  result  in  a  six-hour  gastric 
residue.  New  growths  (more  commonly  carcinomas)  and 
adhesions  from  inflammatory  processes  are  the  usual  causes  of 
stenosis.  Unless  a  tumor  mass  can  be  palpated,  the  nature  of 
the  obstructing  lesion  can  hardly  be  predicted,  nor  can  its  exact 
seat  usually  be  determined.  Multiple  obstructions  of  shght 
degree,  as  evinced  by  numerous  collections  of  barium  from  the 
six-hour  meal  scattered  irregularly  through  the  small  bowel, 
have  been  observed  in  tuberculous  enteritis  and  peritonitis. 
Not  uncommonly,  however,  a  few  small  detached  masses  of 
barium  will  lag  far  behind  the  bulk  of  the  meal  in  a  normal 
intestine,  and  these  should  not  be  hastily  seized  upon  as  proof 
of  obstruction. 

The  Abnormal  Ileum. — Since  the  terminal  portion  of  the 
ileum  can  be  well  visualized,  as  a  rule,  it  is  perfectly  feasible 
by  the  roentgen  examination  to  detect  abnormal  variations 
of  its  position,  mobility,  size,  contour,  and  motility. 

The  most  frequently  noted  displacem.ent  of  the  lower  ileum 
is  ''ptosis,"  being  rather  constant  in  persons  of  the  enteroptotic 
habitus,  and  these  constitute  a  large  percentage  of  all  cases 
examined.  The  significance  of  such  "ptosis"  is  variously 
regarded,  but  when  it  is  in  harmony  with  the  general  make-up 
of  the  individual,  its  importance  should  not  be  exaggerated. 
Often  several  loops  are  situated  deep  in  the  true  pelvis,  and 
from  here  the  terminal  segment  makes  a  steep  ascent  to  the 
ileocolic  juncture.  Displacement  in  any  direction  may  be  the 
result  of  pelvic  tumors.  With  failure  of  the  first  part  of  the 
colon  to  orient  itself  (incomplete  torsion),  the  ileocohc  juncture 
may  lie  on  the  outer  aspect  of  the  large  bowel.  In  the  rare 
cases  of  non-rotation  of  the  colon  and  situs  inversus  the  ileum 
or  its  terminal  portion  will  be  correspondingly  situated. 

Dilatation,  consequent  upon  obstruction,  may  be  demon- 
strable. Proximal  to  a  severe  stenosis  the  dilatation  may  be 
extraordinary,  and  the  ileum  may  be  distended  to  the  size  of 


384  THE    SMALL    INTESTINE 

the  colon.  Definite  narrowing  of  the  ileal  lumen  is  sometimes 
seen  in  the  last  few  inches  of  its  course,  resulting,  as  a  rule, 
from  adhesion-producing  pericecal  inflammation.  Very  often, 
however,  the  contents  of  this  part  of  the  ileum  are  seen  strung 
out  irregularly  when  no  organic  constriction  is  present. 

The  mobility  of  the  ileum  should  be  in  correspondence  with 
its  accessibility  to  palpation  and  the  degree  of  abdominal  relaxa- 
tion. Fixation  by  adhesions  from  pathologic  processes,  which 
originate  for  the  most  part  in  the  appendix  or  cecum,  may  be 
shown  by  immobility  of  the  affected  segment  upon  manipula- 
tion and  change  of  the  patient's  position.  Such  adhesions 
may  also  produce  localized  irregularities  in  the  contour  of 
the  gut. 

The  term  kink,  which  would  imply  a  sharp  angulation  of 
the  bowel,  is  very  often  applied  to  localized  narrowing  with 
fixation,  whether  or  not  angulation  is  present.  What  seems  to 
be  acute  flexions  of  the  bowel  are  frequently  due  merely  to  the 
plane  in  which  the  loops  are  viewed. 

The  bulk  of  the  six-hour  barium  meal  heretofore  described 
will,  under  average  and  normal  conditions  of  gastro-intestinal 
motility,  be  evacuated  from  the  ileum  within  six  to  eight  hours. 
Any  considerable  delay  of  clearance  beyond  this  time  demands 
investigation.  If  the  gastric  and  upper  intestinal  clearance  has 
been  normal,  a  prolonged  delay  in  the  lower  ileum  is  indicative 
of  obstruction.  Stenosis  of  high  grade  may  result  in  ileal  reten- 
tion for  many  hours  or  even  days.  The  seat  of  obstruction  is 
likely  to  be  near  the  cecum  and  the  more  common  causes  are 
appendiceal  inflammation,  cancer,  and  ileocecal  tuberculosis. 
Congenital  stenosis  at  the  ileocecal  valve,  though  rare,  is  a  possi- 
bility. In  addition  to  marked  retention  or  delay  there  will 
nearly  always  be  other  signs  of  organic  obstruction,  such  as 
demonstrable  local  narrowing,  fixation  at  the  site  of  stenosis, 
and  dilatation  of  the  proximal  gut.  Between  the  cases  which  are 
clearly  normal  and  those  with  definite  signs  of  obstruction  other 
than  prolonged  delay,  there  are  cases  in  which  the  progress  of 
the  meal  is  somewhat  retarded,  but  proof  of  any  mechanical 


KEFERENCES  385 

obstacle  is  lacking.     Some  of  the  exponents  of  stasis  consider 
such  cases  as  belonging  to  this  class. 

REFERENCES 

1.  Cannon,  W.  B.:  "The  Mechanical  Factors  of  Digestion."     1911, 

Longmans,  Green  &  Co.,  New  York,  130-147. 

2.  Hertz,  A.  F.:  "Constipation  and  Allied  Intestinal  Disorders." 

H.  Frowde,  London,  1909,  3-5. 

3.  Faulhaber,  M.:  In  Rieder-Rosenthal  "Lehrbuch  der  Ront- 

genkunde."     J.  A.  Barth,  Leipsig,  1913,  i,  560. 

4.  Beclere  et  Meriel:  "L'exploration  radiologique  dans  les  affec- 

tions chirurgicales  cle  I'estomae  et  de  I'intestin."     25  Congres 
Francais  de  Chir.,  1912,  73-74. 


25 


CHAPTER    XIX 
DUODENAL  ULCER 

Though  known  for  a  century,  it  is  only  during  the  past  de- 
cade that  duodenal  ulcer  has  become  firmly  grounded  as  an 
anatomo-pathologic  entity  of  great  practical  moment,  and  the 
frequency  of  its  incidence  has  led  to  a  rapidly  increasing  knowl- 
edge of  the  condition.  Its  importance  is  shown  by  the  fact  that 
in  the  Mayo  Clinic  alone,  more  than  2300  cases  have  been  proved 
by  operation,  and  a  great  number  have  been  diagnosed  but  not 
operated  on. 

In  the  past,  ulcer  of  the  duodenum  has  no  doubt  been  con- 
founded with  ulcer  at  the  pyloric  end  of  the  stomach,  partly 
because  of  the  assumption  that  any  ulcer  found  in  the  vicinity 
of  the  pylorus  must  necessarily  be  gastric,  and  partly  because 
of  the  difficulty  of  determining  the  exact  site  of  the  pylorus. 
In  1907,  W.  J.  Mayo^  called  attention  to  the  pyloric  veins  as  a 
landmark  corresponding  accurately  to  the  pyloric  sphincter. 
More  careful  determination  of  the  pyloric  site  has  resulted  in 
finding  that  the  ratio  of  frequency  between  duodenal  and  gastric 
ulcer  is  far  greater  than  had  been  supposed,  being  now  stated  as 
three,  and  even  four,  to  one. 

Symptoms. — The  symptom-complex  in  a  typical  case  of 
duodenal  ulcer  is  emphatic  and  convincing.  The  "hunger- 
pain,"  a  burning  or  gnawing  epigastric  distress,  coming  two 
hours  or  more  after  meals  and  late  at  night,  and  quickly  re- 
lieved by  food  or  drink;  the  exaggeration  of  the  subsequent 
distress  by  acid  and  fibrous  foods,  such  as  fruits  and  coarse 
vegetables;  the  periodicity  of  the  attacks,  lasting  for  weeks, 
with  intermissions  of  weeks  or  months;  the  hyperacidity,  sour 
eructations,  and  occasionally  also  hematemesis  or  tarry  stools, 
all  combine  to  form  a  significant  clinical  picture.     So  nearly 

386 


PATHOLOGY  387 

characteristic  is  this  syndrome  that  it  has  easily  taken  first 
rank  in  the  diagnosis.  Nevertheless,  it  is  not  infallible,  for 
similar  clinical  histories  are  often  elicited  in  cases  of  gastric 
ulcer,  gastric  cancer,  cholecystitis  and  appendicitis.  More- 
over, the  history  in  duodenal  ulcer  is  frequently  atypical  and 
indecisive.  Errors,  both  of  omission  and  commission,  are  an 
inevitable  consequence  of  all  subjective  diagnoses,  and  the 
effort  is  constant  to  supplement  or  supplant  subjective  methods 
by  more  exact  objective  methods.  In  duodenal  ulcer  the  a;-ray 
usually  provides  the  desired  objective  data.  Even  when  the 
roentgen  examination  does  not  speak  independently  and  with 
certitude,  it  aids  in  excluding  or  confirming  the  simulants  of 
duodenal  ulcer,  and  thus  furnishes  adjunctive  information  to 
the  clinician  which  may  establish  a  decision.  Efficiency  in  the 
roentgenologic  diagnosis  of  duodenal  ulcer  has  been  developed 
only  in  recent  years,  and  considerably  after  the  a:-ray  had 
become  an  accepted  aid  in  the  diagnosis  of  gastric  ulcer  and 
other  lesions  of  the  digestive  tract.  The  anatomical  differences 
between  the  stomach  and  duodenum,  the  thinness  of  the 
duodenal  wall,  the  lack  of  a  sphincter  to  prevent  rapid  egress 
of  the  opaque  meal  from  the  duodenum,  all  seemed  to  be 
insuperable  obstacles  to  obtaining  direct  signs  similar  to  those 
of  gastric  ulcer.  Thus,  for  some  time  the  only  signs  generally 
recognized  were  the  secondary  manifestations  in  the  stomach, 
and,  in  the  main,  diagnosis  by  the  roentgen-ray  was  less  accurate 
than  by  the  anamnesis.  A  more  extended  experience  has  shown, 
however,  that  besides  the  gastric  findings,  which  are  often 
sufficiently  diagnostic,  it  is  possible  in  most  instances  to  obtain 
more  direct  signs  of  the  duodenal  lesion.  At  present,  while  the 
roentgen  diagnosis  is  not  errorless,  its  efficiency  is  fairly  pro- 
portionate to  the  thoroughness  of  the  examination,  and  by 
its  objective  nature  is  more  persuasive  than  the  clinical  diagnosis. 
Pathology. — To  roentgenologists  the |  pathologic  anatomy 
of  duodenal  ulcer  is  of  more  than  passing  interest,  since  the 
location  and  character  of  the  ulcer  directly  affect  its  roentgeno- 
logic demonstrability.     Of  prime  importance  is  the  fact  that 


388  DUODENAL    ULCEK 

more  than  nine-tenths  of  these  ulcers  occur  in  the  first  inch 
and  a  half  of  the  duodenum,  and  usually  on  the  anterior  wall 
(Fig.  324).  Less  than  a  tenth  of  them  are  more  distally  situ- 
ated, and  these  may  be  found  in  any  part  of  the  duodenum,  even 
its  third  or  fourth  portion.  Commonly  single,  the  ulcer  may 
have  a  companion,  a  ''kissing"  or  contact  ulcer,  on  the  opposite 
wall,  or  several  ulcers  variously  grouped  and  in  various  stages 
of  evolution,  may  be  present.     Macroscopically,  the  appear- 


FiG.  324. — Drawing  showing  small  ulcer  in  the  anterior  wall  of  the  duodenum. 

ance  of  an  ulcer  depends  upon  its  age  and  the  resulting  amount 
of  scar-tissue  (Fig.  325).  A  recent  ulcer  may  be  so  small  and 
shallow  (Fig.  326)  that  no  marked  evidence  of  it  can  be  seen  on 
the  outer  coat  of  the  bowel;  its  presence  is  determined  by  the 
surgeon  by  palpation  of  the  slightly  thickened  ulcer-area,  which 
may  also  be  hyperemic,  or  may  show  petechise  after  rubbing 
with  the  finger  or  with  gauze.  With  the  majority  of  ulcers, 
however,  external  scarring  is  visible,  but  this  may  occur  without 
marked  contraction  or  deformity.     The  more  ancient  callous 


PATHOLOGY  389 

ulcers  with  extensive  cicatricial  contraction,  cause  deformity 
and  often  stenosis.  While  an  old  ulcer  may  show  a  punehed- 
out  crater  of  appreciable  depth,  it  is  notable  that  the  excavation 
is  often  superficial.  Regarding  this,  W.  J.  Mayo^  says:  "The 
mucosa  of  the  duodenum  is  thin,  smooth  and  granular,  and 
chronic  duodenal  ulcers  may  not  therefore  have  the  character- 
istics we  have  learned  to  expect  from  experience  with  gastric 


Fig.  325. — Photograph  of  excised  ulcer.     Crater  at  c. 


Fig.  326. — Photograph  of  excised  ulcer.     Crater  at  c. 

ulcers.  I  haA^e  excised  a  number  of  duodenal  ulcers  in  which 
there  was  considerable  scar-tissue  in  the  submucosa  and  muscu- 
laris  and  marked  evidence  of  localized  peritonitis;  yet  the  actual 
ulcer  was  a  mere  slit  or  dimple  surrounded  by  an  eroded,  dis- 
colored patch  of  mucosa.  This  is  the  type  of  ulcer  which  occurs 
on  the  anterior  wall  unless  there  is  a  corn-like  thickening  over 
the  top  of  the  ulcer,  in  which  case  it  will  have  the  size,  depth 
and  callus  characteristic  of  gastric  ulcer." 


390  DUODENAL    ULCER 

A  high  percentage  of  ulcers  penetrate  to  the  serosa  or  per- 
forate the  duodenal  wall.  The  perforation  may  be  sealed  by 
the  adhesion  of  adjacent  tissues,  or  the  ulcerative  process  may 
invade  the  pancreas  or  liver  and  produce  an  accessory  pocket 
(pseudo-diverticulum) ,  similar  to  that  of  perforating  gastric 
ulcer.  An  actual  diverticulum,  or  at  least  a  distinct  pouching 
of  the  gut,  is  sometimes  seen  proximal  to  a  stenosing  ulcer. 
While  no  adhesions  are  found  in  the  majority  of  cases  of  duo- 
denal ulcer,  they  are  a  natural  consequence  of  perforation,  occur 
sometimes  with  the  chronic  non-perforating  type,  and  are  seen 
exceptionally  in  association  with  very  small  ulcers.  MaUgnancy 
developing  upon  a  strictly  duodenal  ulcer  is  exceedingly  rare, 
although  a  gastric  cancer  has  occasionally  been  known  to  develop 
on  a  duodenal  ulcer  which  had  extended  to  the  gastric  side  of 
the  pyloric  ring. 

Technic. — The  technic  of  the  roentgenologic  examination 
for  duodenal  ulcer  is  practically  inseparable  from  that  of  the 
gastric  examination,  for  the  secondary  signs  of  duodenal  ulcer 
are  manifested  chiefly  in  the  stomach.  Hence,  the  six-hour 
meal,  the  barium-water,  and  the  barium-pap  with  roentgeno- 
scopy and  roentgenography  (page  75)  are  all  either  necessary 
or  advantageous.  In  addition  to  the  gastric  examination,  the 
principal  aim  is  to  visualize  the  duodenal  contour  adequately 
and  satisfactorily.  Often  this  can  be  attained  during  the  routine 
vertical  screen-examination.  By  manipulating  the  stomach, 
the  barium-water  and,  though  somewhat  less  readily,  the  barium- 
pap  also,  can  usually  be  forced  through  the  pylorus  in  quantity 
sufficient  to  fill  the  duodenal  bulb.  To  obtain  a  clear  view  of 
the  latter,  it  is  most  often  necessary  to  rotate  the  patient  slightly 
to  the  right  so  as  to  bring  the  shadow  of  the  bulb  away  from  that 
of  the  spine.  Exceptionally,  when  the  stomach  is  of  the  acute 
fish-hook  type  and  the  bulb  lies  very  near  the  lesser  curvature, 
rotating  the  patient  a  little  to  the  left  may  show  it'more  clearly. 
We  have  found  that  examination  of  the  patient  recumbent  on 
the  screen-table  has  an  advantage  occasionally  over  the  upright 
position  by  securing  better  filling  of  the  duodenum.     More 


TECHNIC 


391 


important  than  the  position  is  securing  relaxation  of  the  pyloric 
sphincter.  Adding  a  dram  of  sodium  bicarbonate  to  the 
barium-water  has  seemed  to  promote  this  relaxation,  and  it  is 
also  furthered  by  the  patient  breathing  deeply  and  relaxing  all 
his  voluntary  muscles.  Ordinarily,  a  fair  view  of  the  cap  will 
be  obtained  within  a  very  few  minutes,  but  in  some  instances 


Fig.  329.  Fig.  330. 

Figs.  327,  328,  329,  330.     Normal  stomachs  and  duodenal  bulbs. 

the  bulb  may  fill  more  completely  after  the  patient  has  rested 
for  a  time  and  physiologic  gastric  evacuation  has  become  more 
pronounced.  Waiting  is  sometimes  also  necessary  to  eUcit 
the  exaggerated  peristalsis  which  is  a  common  accompaniment 
of  duodenal  ulcer.  Blocking  the  distal  duodenum  by  manual 
pressure,    or   with   Holzknecht's   distinctor,    sometimes  favors 


392  DUODENAL    ULCER 

duodenal  distension  and  hence  a  better  delineation  of  its 
contour. 

In  a  large  percentage  of  cases,  if  the  examiner  is  experienced, 
the  screen-examination  alone  will  be  fairly  decisive  as  to  the 
presence  or  absence  of  duodenal  ulcer.  Either  a  definitely 
deformed  or  a  definitely  normal  bulbar  contour  will  be  seen, 
or  the  secondary  gastric  signs  will  affirm  the  diagnosis.  In  all 
doubtful  cases  plating  is  requisite.  In  making  plates  the  re- 
cumbent position  is  most  convenient,  with  the  patient  lying  on 
his  abdomen  and  rotated  a  trifle  toward  either  side  or  in  what- 
ever angle  at  which  the  bulb  was  seen  most  clearly  on  the  screen. 
Special  tables  are  obtainable  by  which  the  image  can  be  seen 
fluoroscopically  and  plates  made  at  any  desired  angle  of  pro- 
jection. Plates  can  be  made  at  intervals,  developing  and  ex- 
amining each  plate  as  made;  when  any  plate  shows  a  normal 
bulb,  or  an  identical  deformity  appears  upon  each  of  several 
plates,  the  examination  may  be  discontinued.  Or,  if  preferred, 
a  series  of  plates  may  be  made  successively  and  studied  to- 
gether. By  either  method  it  is  imperative  that  the  number 
o%)lates  be  sufficient  to  support  a  positive  opinion.  If  economy 
is  desired,  devices  can  be  had  by  which  four  or  more  exposures 
can  be  made  on  different  parts  of  the  same  plate. 

Roentgen  Signs. — The  roentgenologic  indications  of  duodenal 
ulcer  may  be  classified  as  follows: 

A.  Direct  signs. 

1.  Deformity  of  the  duodenal  contour. 

B.  Indirect  signs. 

1.  Alterations  of  gastric  tone. 

2.  Alterations  of  gastric  peristalsis. 

3.  Alterations  of  gastric  motility. 

4.  Gast1:-ospasm. 

5.  Tenderness  localized  to  the  duodenum.  ■ 

Direct  Signs. — 1.  Deformity  of  the  duodenal  contour,  more  spe- 
cifically of  its  first  portion,  the  bulbus  duodeni,  or  cap,  was  first 
established  as  a  practicable  sign  of  duodenal  ulcer  by  Lewis 


DIRECT    SIGNS  393 

Gregory  Cole^  of  New  York,  who  developed  the  plan  of  "serial 
roentgenography,"  which  in  essence  consists  in  making  numerous 
roentgenograms  successively  and  studying  them  in  sequence. 
On  theoretical  grounds,  the  method  did  not  seem  to  be  either 
convenient  or  wholly  trustworthy,  and  was  regarded  skepti- 
cally by  many  roentgen  workers,  including  ourselves.  The  diffi- 
culty of  obtaining  a  completely  filled  cap,  the  often  insignificant 
anatomical  changes  produced  by  the  ulcer,  and  the  fact  that 
bulbar  distortion  might  be  due  to  causes  other  than  ulcer  were 
urged  as  objections.  However,  more  careful  investigation  has 
proved  that  bulbar  deformity  is  feasible  of  demonstration  and 
stands  first  among  the  roentgenologic  signs  in  diagnostic  value. 
The  assumption  that  the  distortion  of  the  cap  represented  the 
organic  alteration  produced  by  the  ulcer  has  contributed 
strongly  to  the  doubt  with  which  this  sign  was  received,  since 
it  is  known  that  many  duodenal  ulcers  do  not  materially  alter 
the  duodenal  topography.  Yet  ulcers  of  this  kind  often  give 
rise  to  marked  bulbar  deformity  in  the  roentgenogram,  quite 
out  of  proportion  to  the  organic  changes  found  at  operation. 
The  deformity  of  the  bulb  in  these  cases  is,  we  are  satisfied, 
solely  or  chiefly  the  result  of  intrinsic  spasm  exactly  similar  to 
the  incisura  of  gastric  ulcer  or  the  spastic  distortion  of  the  pars 
pylorica  so  often  seen  associated  with  prepyloric  ulcers.  On 
this  hypothesis  it  is  possible  to  understand  why  the  distortion 
of  the  bulbar  shadow  is  more  exaggerated  than  the  deformity 
seen  at  operation.  Absence  of  spasm  would  also  explain  why 
in  some  cases  of  ulcer  no  irregularity  of  the  bulb-shadow 
is  present  (Fig.  331).  The  bulbar  deformities  more  or  less 
characteristic  of  duodenal  ulcer  might  thus  be  divided  into 
three  general  classes:  (1)  Those  due  to  organic  distortion;  (2) 
those  due  to  organic  changes  plus  spasm;  (3)  those  which  are  pro- 
duced by  spasm  only.  In  appearance  the  following  types  are 
noteworthy : 

a)  General  distortion  with  sharply  outlined  projections 
and  indentations,  giving  the  bulb  the  semblance  of  a  miniature 
pine-tree  or  a  bit  of  branched  coral.     This  sort  of  bulb  almost 


394 


DUODENAL    ULCER 


always  means  duodenal  ulcer   (Fig.   332).     The  distortion    is 
largely  due  to  spasm,  this  element  being  persistent  and  unvary- 


FiG.  331. — Apparently  normal  bulb,  b.     Duodenal  ulcer  found  at  operation. 


Fig.  332. — General  distortion  of  bulb,  b. 

ing.  In  the  classic  cases  of  this  type  the  entire  contour  of  the 
bulb  is  deformed;  in  others  only  one  lateral  border  is  distorted 
(Fig.  333). 


DIRECT    SIGNS 


395 


b)  Deformity  of  the  basal  border.     Instances  are  not  infre* 
quently  encountered  in  which  the  base-hne  alone  of  the  bulb  is 


Fig.  333. — Unilateral  distortion  of  bulb,  b. 


Fig.  334. — Deformity  of  basal  border,  b. 


irregular.  Most  often  the  distortion  is  seen  as  a  shaded  filling- 
defect,  and,  though  definitely  recognizable,  may  be  quite  small 
(Fig.  334). 


396 


DUODENAL    ULCER 


c)  The  niche-type.  The  excavation  of  the  ulcer  is  seen 
as  a  barium-filled  recess  projecting  from  the  bulbar  chamber. 
It  varies  from  a  wheat  grain  to  larger  in  size,  and  its  barium 


Fig.  335. — Niche-type  of  bulbar  deformity.     Niche  at  n. 


Fig.  336. — Incisura-type  oi  bulbar  deformity.     Incisura  at  i. 

content  is  often  denser  than  that  in  the  rest  of  the  bulb  (Fig. 
335).  The  niche  may  or  may  not  be  accompanied  by  organic 
or  spastic  deformity  elsewhere  in  the  bulb. 


DIRECT    SIGNS 


397 


d)  The  incisura-type  of  deformity.  The  incisura  may  be 
single  or  bilateral  (hour-glass).  It  is  usually  small  but  sharply 
outlined,  is  evidently  spastic,  presumably  occurs  in  the  plane 
of  the  ulcer,  and  may  be  the  sole  abnormality  of  contour 
observed  (Fig.  336). 

e)  In  occasional  instances  the  bulb  is  represented  by  a  very 
small  but  compact  mass  of  barium.  There  is  no  particular 
irregularity  of  contour,  but  the  bulbar  shadow  is  abnormally 
small  (Fig.  337).     Sometimes  this  sort  of  bulb  is  produced  by 


Fig.   337. — Diminutive  balb,  b. 


an  ulcer  stenosing  the  duodenum,  so  that  only  the  proximal 
portion  of  the  bulb  is  filled.  But,  unless  other  signs  of  obstruc- 
tion (gastric  retention,  antral  dilatation,  etc.)  are  also  present, 
a  diminutive  cap  should  not  be  considered  indicative  of  ulcer, 
since  it  may  exist  normally,  or  may  be  only  partially  filled  and 
thus  appear  small. 

/)  The  accessory  pocket  of  a  perforating  ulcer  which  has 
invaded  tissues  outside  the  duodenum,  shows  as  a  projection 
from  the  bulbar  contour   (Fig.   338).     It  may  be  rounded  or 


398 


DUODENAL   ULCER 


Fig.  338. — Accessory  pocket,  b,  of  perforating  duodenal  ulcer. 


Fig.  339. — Diverticular  sac  at  d,  in  a  case  of  duodenal  ulcer. 


DIRECT    SIGNS  399 

uneven  in  outline,  and  its  contents  may  be  arranged  in  layers 
of  gas,  fluid  and  barium.  Often  it  contains  a  residue  from  the 
six-hour  meal. 

g)  A  diverticulum  also  appears  as  a  sac-like  addition  to  the 
bulb  proximal  to  the  site  of  the  ulcer.  As  a  consequence,  the 
basal  portion  of  the  bulb  is  usually  enlarged  (Fig.  339).  Since 
a  diverticulum  is  commonly  associated  with  a  stenosing  ulcer, 
other  indications  of  obstruction  will  generally  be  noted  also. 

The  foregoing  deformities  have  all  been  described  as  per- 
taining to  the  bulb,  because  ulcers  are  more  commonly  situated 
in  this  part  of  the  duodenum.  Ulcers  seated  in  other  segments 
of  the  duodenum  doubtless  produce  similar  deformities,  but 
they  are  more  difficult  to  recognize  by  the  rc-ray.  Distortion 
of  the  bulb  is  not  always  easy  to  determine.  With  experience 
the  observer  soon  becomes  famihar  with  the  gross  and  typical 
deformities  which  are  pathognomonic  of  ulcer.  Likewise,  when 
the  bulb  fills  completely  and  is  of  normal  contour,  the  fact  is 
readily  apparent.  But  to  distinguish  a  deformed  cap  from  one 
which  is  only  partially  filled  is  oftentimes  most  troublesome 
(Figs.  340  and  341).  Cases  without  ulcer  are  frequently  met 
with  in  which  the  bulb  as  seen  on  the  screen  and  on  plates, 
especially  the  latter,  fails  to  show  a  normal  contour,  simply 
because  of  incomplete  filling.  It  is  somewhat  characteristic 
of  these  cases  that  the  defective  or  unfilled  area  usually  shifts 
its  situation,  as  shown  by  careful  comparison  of  the  plates  or 
superposing  them,  and,  as  a  rule,  if  the  examination  is  con- 
tinued a  normal  filled  bulb  will  finally  be  obtained.  A  bulb  of 
apparently  normal  and  fairly  regular  outhne  is  sometimes  on 
closer  inspection  found  to  be  eccentrically  placed  with  respect 
to  the  pyloric  canal,  so  that  the  major  part  of  the  cap-base 
visible  lies  on  one  or  the  other  side  of  the  pyloric  axis.  In 
reality  only  a  part  of  the  bulb  is  seen,  and  the  examination  must 
be  continued  until  a  normal  bulb  with  a  symmetrical  base  or  a 
positive  and  unvarying  deformity  is  shown. 

The  significance  of  a  deformity  does  not  depend  on  its  size 
but    on   its    constancy.     It    is    incumbent,    therefore,    on    the 


400 


DUODENAL    ULCER 


examiner  to  make  his  observations  with  extreme  care  lest  he 
overlook  any  relatively  minute  irregularities  of  contour,  but 
he  must  also  make  certain  of  their  persistence.     In  an  over- 


FiG.  340. — Bulb  partly  filled  and  resembling  the  deformed  bulb  of  duodenal  ulcer. 

See  Fig.  341. 


Fig.  341. — Filled  bulb  of  normal  contour.      Same  case  as  in  Fig.  340. 

whelming  preponderance  of  cases,  a  constant  bulbar  deformity 
means  duodenal  ulcer.  It  is  not  absolutely  diagnostic,  since 
distortion  of  the   duodenal  shadow  may  also  result  from  an 


DIKECT   SIGNS 


401 


inflammatory  adhesion-producing  process  in  the  right  upper 
abdominal  quadrant,  notably  pericholecystitis,  or  from  cancer 
of  the  duodenum,  or  possibly  from  purely  reflex  spasm  set  up 
by  conditions  outside  the  duodenum.  While  bulbar  deformity 
from  adhesions  about  the  gall-bladder  does  occur  occasionally 
(Fig.  342)  it  is  not  a  common  cause  of  error,  and  we  have  seen 
cases  in  which  the  duodenum  was  matted  in  adhesions,  yet  the 
contour  of  its  lumen  was  not  deformed  in  the  roentgenogram. 
Cancer  of  the  duodenum  is  so  rare  that  it  should  be  thought  of 
last  of  all. 


Fig.  342. 


-Hour-glass  deformity  of  duodenum  due  to  delicate  adhesions  from  a  peri- 
cholecystitis. 


As  to  the  possibility  of  duodenal  deformity  by  extrinsic 
spasm,  it  must  be  admitted  that  other  portions  of  the  alimentary 
tube  are  affected  by  reflex  spasm  originating  from  causes  outside 
the  digestive  canal,  and  presumably  the  duodenum  is  not  an 
exception.  However,  we  cannot  point  to  a  specific  instance  in 
which  a  persistent  and  unchanging  bulbar  distortion  was  be- 
lieved to  be  due  to  this  cause.  Shifting  and  intermittence  com- 
monly characterize  extrinsic  spasm,  and  if  the  duodenum  were 


26 


402 


DUODENAL    ULCER 


thus  affected,  the  observer  would  probably  be  unable  to  dis- 
tinguish it  from  incomplete  filling  due  to  a  scanty  flow  through 
the  pylorus,   or  rapid  duodenal  evacuation,  or  both.     Pressure 


Fig.  343. — Distortion  of  bulb  by  pressure  against  the  spine. 


Fig.  344. — Gastric  hypertonus  in  a  case  of  non-obstructive  duodenal  ulcer. 

against  the  spine  may  deform  the  bulbar  outline,  especially  its 
inner  border,  but  by  using  both  screen  and  plate  the  cause 
should  be  evident  (Fig.  343).     The  smooth,  concave  indentation 


INDIRECT   SIGNS  403 

of  the  outer  border  of  the  cap,  sometimes  produced  by  the  gall- 
bladder, has  no  resemblance  to  the  irregular  deformity  of  ulcer. 
The  fact  has  been  mentioned  that  duodenal  ulcer  may  exist 
without  detectable  distortion  of  the  bulbar  shadow.  Such 
instances,  however,  are  relatively  uncommon,  and  the  observer 
should  consistently  report  them  as  roentgenologically  negative. 
Indirect  Signs. — 1.  Alteration  of  gastric  tone.  The  most 
common  change  of  gastric  tone,  associated  with  duodenal  ulcer, 
is  to  a  hypertonus  (Fig.  344).  This,  together  with  hyper- 
peristalsis  and  hypermotility,  constitutes  a  triad  of  ''hypers" 
which  was  given  early  recognition  as  being  rather  strongly 
indicative  of  duodenal  ulcer.  The  hypertonus  may  be  explained 
upon  either  of  two  grounds:  First,  it  may  occur  simply  as  a 
reflex  from  the  irritated  ulcer — a  spastic  increase  of  tone  which 
stops  short  of  the  general  reflex  gastrospasm  familiar  as  a 
sequence  of  numerous  conditions  outside  the  stomach.  Second, 
it  may  result  from  the  effort  to  overcome  beginning  stenosis  of 
the  duodenum,  whether  due  to  contraction  of  the  ulcer-scar 
or  duodenal  spasm.  A  compensatory  hypertonus  of  this  sort 
preceding  muscular  hypertrophy  would  be  a  natural  and  first 
response  to  distal  obstruction.  Whatever  the  reason,  hyper- 
tonus is  seen  with  the  majority  of  duodenal  ulcers,  and  perhaps 
more  frequently  in  this  than  in  any  other  condition.  True,  it 
occurs  also  as  a  normal  feature  of  the  steer-horn  stomach  seen 
now  and  then  in  persons  of  the  broad  habitus,  and  is  an  occasional 
accompaniment  of  various  pathologic  conditions  other  than  duo- 
denal ulcer.  With  markedly  obstructing  duodenal  ulcer,  if  of 
long  standing,  there  is  a  gradual  failure  of  compensation  and  the 
stomach  becomes  hypotonic.  If  of  moderate  degree  the  effect 
may  be  chiefly  noticeable  in  the  antrum,  which  is  larger  than 
normal,  and  the  examiner  soon  begins  to  regard  antral  dilatation 
as  more  or  less  significant.  In  the  extreme  degrees  of  hypotonus 
the  entire  stomach  as  well  as  the  antrum  is  expanded  to  immense 
size,  the  condition  is  obviously  one  of  dilatation  rather  than 
functional  atony,  and  the  existence  of  obstruction  is  practically 
certain  (Fig.  345). 


404 


DUODENAL    ULCER 


Fig.  345. — ]^Iarked  gastric  hypotonus;  obstructive  duodenal  ulcer. 


Fig.  3-46. — Hj-perperistalsis;  four  waves  running. 


INDIEECT   SIGNS  405 

2.  Alterations  of  Gastric  Peristalsis. — Hyperperistalsis  is  nota- 
ble in  a  large  proportion  of  cases,  perhaps  60  per  cent,  or  more. 
It  varies  from  a  slight  increase  of  wave-depth  and  frequency  to 


Fig.  347. — Hyperperistalsis.     See  Fig.  348. 


Fig.  348. — Same  case  as  in  Fig.  347.     In  this  roentgenogram,  taken  within  a  min- 
ute after  the  one  shown  in  Fig.  347,  the  stomach  is  practically  at  rest. 

a  tempestuous  energy  of  contraction.  It  is  most  exaggerated 
in  the  obstructive  cases,  but  it  occurs  also  when  there  is  no 
obstruction.     A  characteristic  feature  is  the  regular  succession 


406  DUODENAL    ULCER 

and  symmetrical  correspondence  of  the  Avaves  on  both  curva- 
tm-es  which  are  equally  indented  (Fig.  346).  Three  or  four 
pairs  are  -seen  in  progress  at  once,  whereas  with  the  media 
described,  only  one  or  two  pairs  are  seen  normally.  A  mere 
exaggeration  of  wave-depth  should  not  be  confounded  with 
hyperperistalsis,  since  an  essential  feature  of  the  latter  is  an 
increase  in  number  of  the  waves,  although  they  may  also 
show  unusual  vigor.  Hyperperistalsis  is  often  intermittent 
in  character,  periods  of  activity  alternating  with  periods  of 
rest  (Figs.  347  and  348).  Its  appearance  is  sometimes  a  little 
delayed  after  the  stomach  is  filled,  but  not  usually  beyond 
five  or  ten  minutes.  Of  course,  the  phenomenon  of  hyper- 
peristalsis is  not  limited  to  duodenal  ulcer.  It  may  accom- 
pany lesions  of  the  gall-bladder  or  appendix,  or  be  seen 
normally  in  the  hypertonic  steer-horn  stomach,  but  in  any  of 
these,  as  a  rule,  is  less  pronounced  than  in  duodenal  ulcer. 
Exaggerated  peristalsis  can  sometimes  be  elicited  by  massage 
of  the  epigastrium  in  normal  cases,  or  by  palpating  a  tender 
appendix;  it  soon  dies  away  when  the  stimulus  ceases.  The 
hyperperistalsis  of  duodenal  ulcer  requires  no  artificial  excita- 
tion. Obstructing  pyloric  and  prepyloric  lesions  are  sometimes 
attended  by  hyperperistalsis,  but  this  is  nearly  always  of  a 
disorderly  character  as  to  the  depth  and  sequence  of  the  waves, 
and  these  are  seen  chiefly  on  the  greater  curvature.  Occasion- 
ally, however,  this  variety  of  peristaltic  exaggeration  accom- 
panies perforating  duodenal  ulcer.  In  estimating  the  degree 
of  peristaltic  actlAdty,  it  is  to  be  remembered  that  peristalsis  is 
more  lively  in  the  recumbent  than  in  the  standing  posture,  and 
that  it  is  influenced  by  the  character  of  the  opaque  meal. 
Comparisons  should  be  made  under  identical  circumstances. 

The  observation  of  antiperistalsis  with  duodenal  ulcer  has 
been  reported.  We  have  noted  it  in  one  or  two  cases  with 
obstruction.  In  the  main,  antiperistalsis  speaks  for  pyloric  or 
pre-pyloric,  rather  than  post-pyloric.  lesions. 

3.  Alteration  of  Gastric  Motility. — A  logical  result  of  hyper- 
tonus  and  hyperperistalsis  is  hypermotihty,  provided  no  marked 


INDIRECT   SIGNS 


407 


Fig.  349. — Copious  initial  clearance  in  a  ease  of  duodenal  ulcer. 


Fig.  350. — Hypermotility.     Advance  of  the  six-hour  meal  well  up  to  splenic  flexure. 


408  DUODENAL    ULCER 

obstruction  has  been  produced  by  the  ulcer.  Rapid  clearance 
of  the  stomach  is  also  furthered  by  the  free  patency  of  the  pylo- 
rus so  often  observed.  During  screen-inspection  the  barium  is 
seen  passing  out  into  the  duodenum  in  a  copious  stream,  not 
quite  so  voluminous  as  that  remarked  with  the  gaping  pylorus 
of  cancer,  but  larger  than  normal  (Fig.  349).  Generally  speak- 
ing, the  spontaneous  initial  clearance  in  cases  of  duodenal  ulcer 
is  either  of  this  profuse  type,  or,  with  marked  obstruction,  ab- 
normally scant,  and  a  moderate,  intermittent  outflow  is  not 
seen  as  under  normal  conditions.  Hypermotility  is  also  evi- 
denced by  the  position  of  the  six-hour  meal,  the  ''head"  of  which, 
instead  of  being  in  the  cecum  or  ascending  colon  as  normal,  may 
be  in  the  transverse  or  even  in  the  descending  colon  (Fig.  350). 
Again  it  must  be  recalled  that  hypermotility  is  not  peculiar  to 
duodenal  ulcer  and  that  it  is  a  common  effect  of  gastric  cancer, 
achyha  and  the  diarrheas.  If  these  be  excluded,  as  can  usually 
be  done  by  considering  the  salient  roentgenologic  and  clinical 
facts,  a  pronounced  hypermotility  hints  strongly  at  the  possi- 
bility of  a  non-obstructing  duodenal  ulcer  being  present. 

On  the  other  hand,  more  than  one-fourth  of  the  ulcers  are 
sufficiently  obstructive  to  produce  a  six-hour  retention  in  the 
stomach  (Fig.  351).  A  residue  in  a  stomach  with  an  unbroken 
contour,  that  is  to  say,  without  any  roentgen  evidence  of  gastric 
ulcer  or  cancer,  should  first  of  all  suggest  duodenal  obstruction, 
the  most  common  cause  of  which  is  duodenal  ulcer.  If,  in 
addition  to  the  gastric  retention,  there  is  typical  gastric  hyper- 
peristalsis,  the  presence  of  a  duodenal  ulcer  is  well-nigh  certain 
(Fig.  352).  In  short,  we  consider  the  combination  of  these  two 
signs  as  being  quite  as  diagnostic  as  any  other  evidence  that  can 
be  obtained,  not  excepting  bulbar  deformity. 

4.  Gastrospasm. — Duodenal  ulcer  is  frequently  associated 
with  spastic  manifestations  in  the  stomach.  The  spasm  is 
rarely  or  never  of  the  total  or  regional  type.  Most  commonly 
it  takes  the  form  of  an  incisura  or  an  hour-glass  contraction 
(Fig.  353).  The  incisura  may  be  extraordinarily  large  and  deep, 
in  which  case  it  usually  travels  toward  the  pylorus  along  with 


INDIRECT   SIGNS 


409 


Fig.  351. — Retention  from  the  six-hour  meal. 


Fig.  352. — Marked  hyperperistalsis ;  large  stomach,  otherwise  normal  pretention  from 
the  six-hour  meal.  The  diagnosis  of  duodenal  ulcer  based  on  these  signs  alone  was 
confirmed  at  operation. 


410 


DUODENAL    ULCER 


Fig.  353. — Hour-glass  stomach  due  to  duodenal  ulcer.  Diagnosis,  gastric  ulcer. 
The  bulb  was  not  investigated  as  to  deformity.  At  operation  a  duodenal  ulcer  was 
found,  with  stomach  negative,  and  no  hour-glass,  the  latter  having  been  relaxed  bj'  the 
anesthesia. 


*mmt^ 


Fig.  354. — Gastric  incisura  in  a  case  of  duodenal  ulcer. 


VALUE    OF    INDIRECT    SIGNS  411 

the  deep  peristaltic  waves,  of  which  it  is  perhaps  an  eccentric 
form.  Again,  the  incisura  is  of  shght  or  moderate  depth,  is 
seen  anywhere  along  the  greater  curvature  and  is  stationary 
(Fig.  354).  Especially  annoying  is  the  fact  that  such  an 
incisura  may  persist  after  belladonna  has  been  given  to  the 
patient  and  thus  arouse  suspicion  of  a  gastric  ulcer.  It  is  a  vex- 
ing exception  to  the  rule  that  spasm  associated  with  conditions 
outside  the  stomach  disappears  after  the  administration  of  an 
antispasmodic.  Other  causes  of  gastrospasm  have  been 
discussed  in  the  chapter  on  this  subject. 

5.  Tenderness  localized  to  the  duodenum  is  included  in  many 
of  the  older  lists  of  ulcer  signs.  In  some  cases  the  tenderness 
is  rather  emphatic  and  limited  to  the  vicinity  of  the  ulcer,  but 
it  may  easily  be  confounded  with  a  tender  gall-bladder,  and  its 
diagnostic  worth  is  trivial. 

Value  of  Indirect  Signs. — The  value  of  all  these  indirect 
signs  depends  considerably  upon  their  frankness,  their  varying 
combination,  and  their  concordance  with  the  general  aspects 
of  the  case.  Hyperperistalsis  associated  with  gastric  retention 
and  a  normal  gastric  outline  is  safely  diagnostic,  and  making 
multiple  plates  in  such  cases  is  superfluous.  Hyperperistalsis 
alone,  if  pronounced,  is  perhaps  a  60  per  cent.  item.  Backed 
by  a  good  clinical  history  it  is  worth  even  more,  but  there  are 
instances  in  which  this  combination  results  from  causes  other 
than  duodenal  ulcer,  so  that  it  is  more  conservative  to  carry 
out  the  serial  plate  examination  in  addition.  There  is  always 
this  to  be  said  of  indirect  signs,  that  where  they  fall  short  of 
establishing  a  diagnosis  they  contribute  to  diagnostic  certainty, 
or,  at  all  events,  guide  the  observer  in  the  right  line  of  inquiry. 

At  the  risk  of  being  tedious  we  must  repeat  the  advice  that 
the  examiner  acquaint  himself  with  the  clinical  history  in  every 
case.  This  knowledge  will  direct  his  particular  attention  to  the 
probable  source  of  trouble  and  will  restrain  him  from  overhasty 
conclusions.  There  is  no  intent  to  suggest  that  the  roentgen- 
ologist should  base  any  diagnosis  on  the  history  only,  or  even 
chiefly — the  clinician  can  do  that.     Nor  should  a  contradict- 


412  DUODENAL    ULCER 

ing  history  swerve  the  roentgenologist  when  his  own  evidence 
is  conclusive.  But  the  anamnesis  and  cUnical  data  in  most 
instances  are  more  or  less  directive  and  eliminative,  so  that  a 
correlation  of  all  the  findings  is  advisable,  as  a  rule.  No  diag- 
nosis can  be  too  strongly  fortified,  and  any  gross  discordance 
between  the  findings  from  all  sources  should  make  the  examiner 
cautious  in  his  opinions.  As  a  corollary  of  this,  he  should  not 
pin  exclusive  faith  to  any  single  method  of  roentgen  examination, 
but  should  make  use  of  every  technic  that  offers  help,  and  weigh 
the  result  as  a  whole. 

Concurrence  of  Duodenal  and  Gastric  Ulcer. — As  mentioned 
elsewhere,  about  15  per  cent,  of  the  cases  of  gastric  ulcer  have 
a  duodenal  ulcer  also.  Hence,  the  examiner  ought  not  to  be 
too  easily  satisfied  with  the  demonstration  of  a  duodenal  ulcer, 
but  should  make  careful  observations  for  a  possible  gastric  ulcer. 

Case  127,835,  woman,  aged  35  years.  During  the  past  eight  or  ten 
years  she  has  been  having  attacks  of  epigastric  pain,  coming  on  one  to 
three  hours  after  meals.  At  first  the  attacks  were  not  severe  and  came 
at  long  intervals,  often  to  one  year.  Chronic  appendix  removed 
seven  years  ago;  not  much  improvement.  Two  years  ago  she  was 
operated  upon  for  gall-stones,  which  were  not  found.  Her  surgeon 
told  her  that  he  ''covered  in"  an  ulcer  of  the  intestine.  She  was 
very  much  improved  for  six  or  eight  months.  Over  a  year  ago  she  was 
treated  by  lavage  and  dieting  for  a  gastric  ulcer,  and  gained  much  relief. 
Present  attack  began  eight  weeks  ago.  A  week  ago  she  vomited  two 
or  three  times  with  relief.  During  the  past  few  months  she  has  lost 
10  or  15  pounds  weight.  Gastric  analysis  r  Stomach  empty.  Hema- 
globin  83.  Roentgen  findings:  Constant  deformity  of  bulb  (Fig.  355). 
Findings  at  operation:  Large,  contracting,  scarred  ulcer  of  duodenum 
just  below  pylorus,  with  adhesions  to  anterior  abdominal  wall  and 
liver.     Operation:  Posterior  gastro-enterostomy. 

Case  124,843,  man,  aged  30  years.  Seven  years  ago  he  had  a  sud- 
den attack  of  very  sharp  and  severe  pain  in  the  right  hypochondrium, 
emesis  of  greenish  vomit,  and  fever,  followed  by  marked  jaundice. 
For  a  year  after  this  by  spells  he  had  subcostal  tenderness,  aggravated 
by  jolting,  together  with  gas,  fullness  and  sour  eructations  after  meals. 
For  three  or  four  years  he  had  very  little  trouble.  He  then  began  to 
have  attacks  lasting  a  month,  of  epigastric  tenderness  with  hunger- 
pain,  relieved  by  light  food  and  aggravated  by  acids,  coffee,  tea  and 


KEPORT    OF    CASES  413 

meat.  Some  months  ago,  for  two  weeks,  he  had  extraordinarily  black 
stools.  For  six  weeks  past  he  has  had  fullness  for  a  half  hour  after 
meals,  then  relief  for  two  hours,  then  hunger-distress.  Four  weeks  ago 
he  again  had  an  acute  attack  of  upper  abdominal  pain  with  fever,  which 
ceased  suddenly,  and  was  not  followed  by  jaundice.  At  present  there 
is  some  rigidity  and  tenderness  in  the  right  hypochondrium.  Total 
acidity  76;  free  60;  combined  16.  Hemoglobin  85;  leukocytes  11,000. 
Roentgen  findings:  Deformity  of  bulb.  Diagnosis:  Duodenal  ulcer 
(Fig.  356).  Findings  at  operation:  Subacute  perforating  duodenal 
ulcer  just  at  the  pylorus.     Pylorus  adherent  to  left  lobe  of  liver. 


Fig.  355.— Case  127,835. 

Adherent  appendix.  Gall-bladder  negative.  Operation:  Posterior 
gastro-enterostomy.  Pylorus  blocked  (Wilms).  Ulcer  covered  with 
omentum.     Appendectomy. 

Case  128,344,  man,  aged  46  years.  Eight-year  history  of  gastric 
attacks,  coming  on  once  or  twice  a  year  and  lasting  three  to  ten  weeks. 
In  these  he  has  a  fullness  and  distress  two  and  a  half  hours  after  meals, 
lasting 'until  the  next  meal  or  alkalies  are  taken.  Eating  soon  after 
the  pain  begins  increases  the  distress.  Much  night  distress  from  10 
p.m.  to  2  a.m.  Very  little  belching  or  sour  eructations.  Total 
acidity  66;  free  54;  combined  12.  Roentgen  findings:  Bulb  deformed. 
Diagnosis:  Duodenal  ulcer  (Fig.  357).  Findings  at  operation :  Large, 
thick,  calloused  ulcer  of  the  duodenum,  anterior  wall,  beginning  just 
below  the  pylorus  and  extending  downward  1}^  inches.  Beginning 
obstruction.     Long    mesocolic    band.     Operation:  Posterior    gastro- 


414 


DUODENAL    ULCER 


Fig.  356.— Case  124,843. 


Fig.  357.— Case  128,344. 


EEPORT   OF   CASES  415 

enterostomy.  Ulcer  covered  in  with  sutures.  Mesocolic  band 
divided. 

Case  142,380,  man,  aged  62  years.  About  three  years  ago  he 
began  having  general  abdominal  pains,  worse  at  the  umbilical  region, 
coming  usually  after  bowels  had  not  moved  for  three  or  four  days,  and 
relieved  by  catharsis.  Never  any  trouble  directly  referable  to  the 
stomach.  Two  months  ago  he  had  an  attack  of  pain  and  vomiting, 
after  a  constipated  period.  For  two  weeks  he  has  had  occasional 
vomiting  though  bowels  are  moving.  Indefinite  history  also  of  heavy 
feeling  at  night,  relieved  by  soda,  and  prevented  by  taking  cathartics. 
Total  acidity  70;  free  60;  combined  10;  no  food  remnants.  Roentgen 
findings:  Retention  of  half  the  six-hour  meal.  Hyperperistalsis. 
Bulbar  deformity.  Diagnosis:  Perforating  duodenal  ulcer  (Fig.  358). 
Findings  at  operation:  Large  ulcer,  anterior  wall  of  duodenum,  per- 
forating into  head  of  pancreas,  forming  tumor  size  of  a  lemon.  Opera- 
tion: Posterior  gastro-enterostomy;  ulcer,  covered. 

Case  146,943,  man,  aged  53  years.  Thirty-year  history  of  trouble 
with  stomach.  Attacks  in  spring  and  fall,  lasting  three  months,  of 
cramps  two  or  three  hours  after  meals  and  at  night  from  12  to  1. 
Well  between  attacks.  No  food  relief;  some  ease  by  soda;  most  relief 
by  drinking  water  and  inducing  vomiting.  Much  sour  stomach;  some 
gas.  Occasional  retention  vomit.  Qualitative  dyspepsia  for  fats, 
acids,  apples,  etc.  Frequently  tarry  stools;  never  vomited  blood. 
Many  years  ago  had  three  attacks  of  severe  abdominal  colic  requiring 
chloroform  for  relief.  No  jaundice,  chills  or  fever.  Weight  loss,  20 
pounds  in  one  month.  Total  acidity  66;  free  52;  combined  14;  no 
food  remnants.  Roentgen  findings:  Retention  of  half  the  six-hour 
barium  meal.  Hj^peristalsis.  Irregular  bulb.  Diagnosis:  Duodenal 
ulcer  (Fig.  359).  Findings  at  operation:  Extensive  ulceration  of  the 
duodenum.  Gall-bladder  negative.  Operation:  Posterior  gastro-en- 
terostomy. 

Case  134,500,  man,  aged  38  years.  For  four  years  he  has  had  at- 
tacks of  very  sour  stomach  coming  any  time  in  the  afternoon  or  night 
and  accompanied  by  dull  epigastric  pain.  He  forces  vomiting  for 
relief.  The  attacks  have  no  relation  to  eating,  and  food  does  not  ease 
although  he  has  taken  a  good  deal  of  soda.  The  trouble  is  fairly  con- 
tinuous, although  he  has  occasional  remissions,  even  to  one  month. 
Three'months  ago  he  vomited  a  large  quantity  of  blood.  Operation 
elsewhere  for  ruptured  appendix  three  years  ago.  Weight  loss,  27 
pounds  in  two  years.  Total  acidity  90;  free  70;  combined  20;  food 
remnants.  Roentgen  findings:  Retention  of  three-fourths  the  meal. 
Hyperperistalsis.     Small  irregular  bulb.     Diagnosis:  Duodenal  ulcer 


416 


DUODENAL   ULCER 


Fig.  358.— Case  142,380. 


Fig.  359.— Case  146,943. 


REPORT    OF    CASES 


417 


(Fig.  360).  Findings  at  operation:  Multiple  ulcers  of  duodenum,  at 
least  three  being  felt.  Large,  dilated  stomach.  One  firm  adhesion 
between  anterior  wall  of  stomach  and  gall-bladder.  Operation: 
Posterior  gastro-enterostomy.     Ulcers  enfolded. 

Case  144,333,  woman,  aged  33  years.  For  two  years,  following 
a  nervous  breakdown  at  that  time,  she  has  had  severe  epigastric  pain, 
coming  on  immediately  after  eating  and  lasting  two  or  three  hours. 


Fig.  360.— Case  134,500. 

Some  relief  by  soda.  Always  feels  best  with  empty  stomach.  Con- 
siderable eructation  of  acid.  For  seven  weeks  past  she  has  had  attacks 
of  vomiting,  coming  on  about  1.30  a.m.  and  preceded  by  sharp  pain  in 
the  epigastrium.  Absolutely  no  abatement  of  symptoms  in  two  years. 
On  liquid  diet  for  six  weeks.  Strength  poor.  Weight  loss,  5  pounds 
in  two  years.  Diffuse  tenderness  upper  abdomen.  Total  acidity  40; 
free  22;  combined  18.  Roentgen 'findings :  Constant  spastic  incisura, 
outer  aspect  of  bulb  near  base.  Diagnosis :  Duodenal  ulcer  (Fig.  361) . 
(This  case  illustrates  the  fact  that  a  small  duodenal  ulcer  can  be  present 

27 


418 


DUODENAL    ULCER 


without  showing  roentgenologically  unless  it  produces  spasm.)  Find- 
ings at  operation:  Definite  smooth  scar  on  duodenum,  l^  inch  below  the 
pylorus,  with  marked  stippling  sign.     Large  stomach  and  dUated  duo- 


FiG.  361.— Case  144,333. 


Fig.  362.— Case  111,247. 

denum.  White  gall-bladder  with  adhesions  about  it.  Definite  chronic 
appendix.  Operation:  Excision  of  ulcer  of  duodenum  and  closure 
as    a    Heineke-Mikulicz    operation.      Cholecystectomy.     Appendec- 


REPORT    OF    CASES  419 

tomy.  Pathologic  report :  Chronic  catarrhal  cholecystitis  (very  early 
''strawberry")-     Duodenal  ulcer.     Chronic  catarrhal  appendicitis. 

Case  111,247,  man,  aged  25  years.  Began  three  months  ago  with 
a  sudden,  sharp,  sticking  pain,  right  costal  margin,  causing  him  to 
double  up  for  a  few  minutes.  Two  or  three  attacks  daily.  Never 
vomited  or  had  to  go  to  bed  on  account  of  pain.  No  chills,  fever,  or 
jaundice.  His  phj^sician  gave  him  some  pills,  after  taking  which,  the 
patient  states,  he  passed  gall-stones.  For  a  month  he  has  had  a  dull 
epigastric  pain  usually  with  empty  stomach,  relieved  by  food  of  any 
sort.  No  gas  or  sour  eructations.  Bowels  regular;  appetite  fair. 
Sleepless  and  nervous.  Total  acidity  44;  free  30;  combined  14.  Some 
tenderness  and  spasm,  right  costal  margin.  Roentgen  findings: 
Diverticulum  of  the  duodenum.  Rather  large  low4ying  stomach 
(Fig.  362).  Findings  at  operation:  Duodenal  ulcer,  1  inch  below 
pylorus  with  marked  contraction,  producing  what  appeared  to  be  a 
diverticulum  from  lower  border  of  duodenum,  size  of  a  tangerine. 
Operation:  Posterior  gastro-enterostomy.  Ulcer  area  covered  in 
with  purse-strings  of  silk. 

Case  91,639,  man,  aged  35  years.  Since  the  age  of  13  he  has  had 
occasional  epigastric  pain  which  was  always  relieved  by  hot  drinks. 
For  eight  years  he  has  had  more  definite  attacks,  once  or  twice  yearly, 
lasting  one  to  three  weeks,  of  gnawing  epigastric  pain,  two  or  three 
hours  after  meals,  relieved  by  food.  The  distress  often  wakes  him  at 
2  a.m.  and  he  takes  a  drink  of  water  or  soda  for  relief.  During  the 
attack  he  loses  weight,  but  regains  it  between  times.  For  two  years 
the  attacks  have  been  accompanied  by  regurgitation  of  sour,  acrid 
fluid.  The  present  attack  has  existed  for  three  months  and  vomiting 
is  a  prominent  feature.  The  vomiting  occurs  four  to  six  hours  after 
meals,  and  sometimes  food  that  had  been  taken  twelve  hours  previously 
is  vomited.  He  has  never  vomited  blood.  Weight  loss,  23  pounds  in 
three  months.  Some  epigastric  tenderness.  Total  acidity  70;  free 
60;  combined  10,  food  remnants.  Roentgen  findings:  Hyperperistal- 
sis.  Retention  of  three-fourths  the  six-hour  meal.  Diagnosis:  Duo- 
denal ulcer  (Figs.  363  and  364).  Findings  at  operation:  Large 
indurated  ulcer  of  duodenum,  showing  evidence  of  recent  perfora- 
tion. Marked  obstruction.  Operation:  Posterior  gastro-enterostomy. 
Ulcer  covered  with  linen. 

Case  158,555,  man,  aged  37  years.  One  year  ago  he  began  to  have 
a  gnawing  epigastric  pain,  coming  two  hours  after  meals  and  relieved 
by  food,  so  that  he  acquired  the  habit  of  eating  five  or  six  times  daily. 
The  pain  gradually  increased  and  he  has  had  to  give  up  his  work.  No 
pain  at  night;  no  nausea;  no  vomiting;  no  hematemesis;  no  tarry  stools. 


420 


DUODENAL    ULCER 


For  six  months,  up  to  a  month  ago,  the  patient  had  a  respite  from  his 
trouble  and  gained  weight  and  strength.  During  the  past  month, 
however,  there  has  been  no  freedom  from  pain.  Weight  loss,  9  pounds 
in  one  month.  Considerable  epigastric  tenderness.  Total  acidity 
92;  free  80;  combined  12.     Roentgen  findings:  Three  different  exami- 


nations with  a  series  of  plates  on  each  occasion  failed  to  show  either  a 
normal  filled  bulb  or  a  constantly  deformed  bulb.  At  operation,  the 
duodenum  was  found  to  be  unusually  large,  and  this  probably  ac- 
counted for  the  failure  to  fill  it  and  show  its  actual  contour  (Figs.  365 
and  366j.     Findings  at  operation:  Ulcer  anterior  superior  duodenal 


REPORT    OF    CASES 


421 


wall,  just  below  pylorus.  Obstruction  first  degree.  Evidence  of 
recent  peritonitis.  Operation:  Posterior  gastro-enterostomy.  Ulcer 
enfolded. 


.-c5^ 


Fig.  365.— Case  158,555. 


•\ 


Fig.  366.— Case  158,555. 


Case  158,688,  woman,  aged  61  years.  For  many  years  she  has  had 
epigastric  pain,  gas,  fullness,  and  sour  eructations,  usually  coming 
directly  after  meals,  and  she  feels  better  with  an  empty  stomach.  She 
has  to  avoid  acids,  apples,  heavy  foods  and  sweets.     During  the  past 


422  DUODENAL    ULCER 

eight  years,  about  twice  a  month,  she  has  had  pain  under  the  right 
costal  margin  and  in  the  epigastrium,  often  coming  about  10  a.m.  and 
lasting  the  remainder  of  the  day.  For  three  months  this  has  been 
much  more  marked,  and  every  night,  or  twice  in  the  night,  she  has  been 
awakened  wath  a  feeling  of  hunger  and  weakness,  quickly  followed  by 
terrific  stabbing  pain  through  the  right  costal  margin  to  back,  and 
lasting  not  more  than  five  minutes.  Stools  often  light.  Weight  loss, 
16  pounds.  Total  acidity  50;  free  40;  combined  10.  Hemoglobin  50. 
Roentgen  findings:  At  the  screen-examination  an  irregular  bulb  was 
seen  and  the  case  was  believed  to  be  one  of  duodenal  ulcer.     However, 


Fig.  367.— Case  158,688. 

the  plates,  as  here  illustrated  (Fig.  367)  showed  an  apparently  normal 
bulb  and  a  negative  diagnosis  was  returned.  Shorth'  before  coming 
to  the  Mayo  Clinic,  this  patient  was  examined  on  three  occasions  by  a 
roentgenologist  who  found  a  small  retention  from  the  six-hour  meal 
but  a  negative  stomach  and  duodenum.  He  concluded  that  the  trouble 
was  probably  a  lesion  of  the  gall-bladder.  Clinical  diagnosis:  Chronic 
cholecystitis.  Gall-stones.  Findings  at  operation :  Chronic  perforat- 
ing duodenal  ulcer,  anterior  superior  wall,  beginning  immediately 
below  the  pylorus.  Very  extensive  adhesions  anterior  right  abdomen. 
Gall-bladder  closely  adherent  and  cause  of  gall-bladder  sj-mptoms. 
At  one  time  evidently  an  acute  peritonitis  and  leakage  due  to  perforat- 
ing duodenal  ulcer.     Operation:  Posterior  gastro-enterostomy. 

Case  106,481,  man,  aged  62  years.     For  twenty-five  years,  con- 


REPORT    OF   CASES 


423 


tinuous,  severe,  burning  sensation  in  epigastrium.  Occasionally  it  is 
less  severe,  but  he  has  not  found  relief  by  any  measure  whatever.  H^ 
has  no  distinct  nausea,  but  at  times  he  feels  as  though  vomiting  might 


Fig.  368.— Case  106,481. 


Fig.  369.— Case  131,731. 


give  relief.  Lately  the  burning  has  become  especially  severe  about 
2  a.m.  Appetite  good,  but  he  does  not  eat  to  satiation,  as  this  is 
followed   by  distress   within  a  half  hour.     Weight  loss,   9   pounds. 


424 


DUODENAL    ULCER 


I"iG-  374.  Fig.  375. 

FiQS.  370,  371,  372,  373,  374,  375.— Examples  of  bulbar  deformity  in  duodenal  ulcer. 


EXAMPLES    OF  BULBAR   DEFORMITY 


425 


Fig.   :-!7S. 


Fig.  379. 


Fig.  380.  Fig.  381. 

Figs.  376,  377,  378,  379,  380,  381.— Examples  of  bulbar  deformity  seen/,in  duodenal 

ulcer. 


426 


DUODENAL    ULCER 


Fig.  386.  Fig.  387. 

Figs.  382,  383,  3  84,  385,  386,  387.— Examples  of  bulbar  deformity  in  duodenal  ulcer. 


EXAMPLES    OF   BULBAR    DEFORMITY 


427 


i 


4Kn 


Fig.    388. — Markedly    deformed    bulb.  Fig.    389. — Lateral   view    showing    de- 

Large  third  portion  of  duodenum.     Opera-       formed     bulb     in     a     case    of    duodenal 
tion:  Duodenal  ulcer;  no  other  lesion.  ulcer. 


Fig.  390.— Duodenal  ulcer;  bulbar 
deformity. 


Fig.  391. — Duodenal  ulcer.     Deformed 
bulb  resembling  a  Maltese  cross. 


Fig.   392. — Antero-posterior  view.     Bulb         Fig.  393. — Same   case  as  in  Fig.   392; 
hidden  by  antrum.     See  Fig.  393.  lateral  view.      Deformity  of  bulb. 


428  DUODENAL    ULCER 

Tenderness  right  costal  margin.  Total  acidity  52;  free  34;  combined 
18.  Roentgen  findings:  Persistent  deformity  of  the  bulb.  Diagnosis: 
Possible  duodenal  ulcer,  or  adhesions,  or  both  (Fig.  368).  Findings  at 
operation:  Chronic  catarrhal  cholecystitis.  Gall-bladder  very  adher- 
ent. Liver  adherent  to  abdominal  wall.  Pylorospasm.  Operation: 
Cholecystectomy. 

Case  131,731,  man,  aged  37  years.  During  the  past  fifteen  years 
he  has  had  gastric  distress,  gas  and  sour  eructations  almost  continu- 
ously, never  being  entirely  free  for  a  day,  and  worse  in  winter.  The  dis- 
comfort comes  on  a  half  hour  after  breakfast  and  becomes  severe  from 
9.00  to  11.30  a.m.  It  is  relieved  by  the  noon  meal  and  recurs  at  1.00 
p.m.  Every  morning  at  3  or  4  o'clock  he  is  awakened  by  it.  Besides 
relief  by  food  he  obtains  partial  rehef  by  soda,  belching,  hot  water, 
etc.  Never  vomits;  no  black  stools.  No  weight  loss.  Succussion 
over  stomach;  tenderness  of  epigastrium.  Total  acidity  60;  free  46; 
combined  14;  no  food  remnants  (twelve-hour  meal).  Eight-hour 
motor  meal  shows  small  amount  of  food  remnants.  Roentgen  findings : 
Large  hypotonic  stomach.  Retention  of  half  the  six-hour  meaL 
Normal  gastric  and  bulbar  contours  (Fig.  369).  Negative  diagnosis. 
Clinical  diagnosis:  Duodenal  ulcer  with  obstruction.  Findings  at 
operation:  Pyloric  obstruction  due  to  an  extensively  adherent  gall- 
bladder, which  is  firmly  bound  to  the  abdominal  wall.  Stone  %  inch 
long  in  tip  of  appendix.  Operation:  Cholecystectomy.  Appendec- 
tomy. 

REFERENCES 

1.  Mayo,  W.  J.:  "The  Contributions  of  Surgery  to  a  Better  Under- 

standing of  Gastric  and  Duodenal  Ulcer."     Annals  of  Surgery, 
1907,  xlv,  810-817. 

2.  Mayo,  W.  J.:  ''Chronic  Duodenal  Ulcer."     Jour.  A.M. A.,  1915, 

Ixiv,  2036-2040. 

3.  Cole,  L.  G.:  "The  Diagnosis  of  Post-pyloric  (Duodenal)  Ulcer  by 

Means  of  Serial  Radiography."     Lancet,  1914,  i,  1239-1244. 


CHAPTER  XX 
MISCELLANEOUS  LESIONS  OF  THE  SMALL  INTESTINE 

Besides  the  bulbar  sacculation  or  diverticulum  incident  to 
obstructive  duodenal  ulcer,  and  the  accessory  pocket  or  pseudo- 
diverticulum  of  perforating  duodenal  ulcer,  diverticula  may 
also  occur  in  the  neighborhood  of  the  ampulla  of  Vater.  These 
may  be  congenital  and  contain  an  islet  of  pancreatic  tissue,  or 
they  may  result  from  pressure-dilatation  in  late  life.  They  are 
chiefly  of  academic  interest.  We  have  not  found  any  roentgen 
observations  of  Meckel's  diverticulum.  Other  than  duodenal 
ulcer,  the  only  important  condition  of  the  small  intestine 
which  is  readily  susceptible  of  demonstration  by  the  x-ray  is 
obstruction.  If  near  either  extremity  of  the  bowel,  the  site 
of  the  obstruction  can  be  shown,  but  not  if  it  is  seated  else- 
where, nor  can  the  nature  of  the  obstruction  be  determined  by 
the  roentgen  signs  alone.  Instances  of  obstruction  from 
different  causes  are  presented  in  the  following  case  reports : 

Case  143,715,  male,  aged  59  years.  The  patient  complains  chiefly 
of  numbness  of  the  extremities  and  gastric  distress.  About  eight 
months  ago  he  had  a  rather  sudden  onset  of  numbness  of  the  distal 
phalanges — ^both  hands.  With  this  was  a  numbness  of  the  toes  which 
has  extended  up  the  inner  side  of  his  legs  and  to  his  body  as  far  as  the 
umbilicus.  For  a  year  he  has  had  attacks  of  gastric  distress  lasting 
a  week  or  ten  days,  coming  three  hours  after  meals  and  at  midnight. 
Relief  obtained  by  soda  and  by  vomiting.  Some  gas  and  sour  eructa- 
tions. He  vomits  at  irregular  intervals,  sometimes  the  entire  meal 
taken  six  hours  previously.  No  hematemesis  or  tarry  stools.  Some 
qualitative  food  dyspepsia  for  acids,  apples,  etc.  Weight  loss,  12 
pounds.  Anemic.  Knee-jerks  absent.  Hemoglobin  55  per  cent. 
Gastric  analysis:  Total  acids,  10;  all  combined;  no  food  remnants. 
Endamoebse  histolytica  in  stools.  Urinalysis  negative.  Roentgen 
findings:  No  retention  from  the  six-hour  meal.  Fairly  active  peris- 
talsis. No  normal  bulb,  but  deformity  inconstant  at  two  extensive 
examinations  (Fig.  394).     Diagnosis:  Indeterminate.     After  medical 

429 


430       MISCELLANEOUS    LESIONS    OF    THE    SMALL    INTESTINE 

treatment,  the  patient  went  to  his  home.  He  returned  to  the  CHnic 
about  nine  months  after  with  his  gastric  symptoms  aggravated,  an 
icterus  of  seven  months  standing  and  marked  weight  loss.     Transfu- 


FiG.  398. — Case  77,400. 


Fig.  397. — Case  77,400. 


sion.  Exitus  lethahs.  At  the  second  visit  of  the  patient,  when  the 
x-ray  might  have  shown  the  site  of  obstruction,  no  roentgen  examina- 
tion was  made.  Autopsy  report:  Carcinoma  of  the  duodenum  which 
involves  the  head  of  the  pancreas  and  partially  occludes  the  common 


REPORT    OF    CASES  431 

bile-duct.  Small  hypernephroma  of  the  left  adrenal.  ^Moderate 
fatty  degeneration  of  liver,  etc. 

Case  139,141,  woman,  aged  51  years.  Several  years  history  of 
occasional  epigastric  pain,  soon  after  meals;  sometimes  forced  vomiting 
for  relief.  The  attacks  were  brief  and  came  at  intervals  of  several 
months.  One  j^ear  ago  she  had  an  unusually  severe  attack  which 
necessitated  morphin  for  relief,  and  again  three  months  ago.  Since 
then  she  has  had  much  epigastric  distress  and  pain  in  stomach  after 
taking  food,  with  burning,  gas,  and  bitter  eructations.  Everj^  second 
day  or  night  she  vomits  large  quantities  of  food  and  bitter  fluid.  Weight 
loss,  30  pounds.  Peristalsis  well  marked.  Total  acidity  18;  free  0; 
combined  18;  food  remnants;  filtrate  800  c.c.  Roentgen  findings: 
Practically  entire  six-hour  meal  retained  in  stomach.  Large  stomach 
and  duodenum.  Pyloric  canal  widely  open.  Stomach  and  bulb 
normal  in  outline  (Fig.  395).  Diagnosis:  Obstruction  in  duodenum 
bej^ond  the  bulb.  Findings  at  operation:  Cancer  of  gall-bladder 
which  had  perforated  against  duodenum  about  4}4  inches  from  the 
pylorus,  causing  contraction  at  that  point  and  dilatation  of  duodenum 
above.  Widely  open  pyloric  ring.  Huge,  dilated  stomach.  Opera- 
tion :  Impossible  to  remove  cancer  because  of  involvement  of  deep  struc- 
tures, ducts,  etc.  Anterior  gastro-enterostomy.  Pathologist's  report: 
Specimen  shows  carcinoma.  Autopsy  report:  Carcinoma  of  gall-blad- 
der associated  with  cholelithiasis  (one  stone),  cholangitis,  etc. 

Case  77,400,  woman,  aged  36  3'ears.  Trouble  with  stomach  since 
girlhood,  six  or  eight  times  a  year.  Cramps  in  epigastriiun,  not 
always  related  to  food,  much  gas  and  rumbling  in  abdomen,  occasional 
vomiting.  For  three  months  past  she  has  had  a  diarrhea  with  seven 
or  eight  watery  movements  daily.  Severe  abdominal  cramps.  Visible 
and  audible  peristalsis.  Stool  examination:  Red  blood  corpuscles, 
pus;  otherwise  negative.  Wassermann  negative.  Roentgen  findings: 
One-fourth  motor  meal  in  stomach  at  six  hours.  Stomach  deformed 
by  distended  loops  of  small  bowel.  Small  bowel  markedly  dilated, 
containing  fluid  and  gas.  Diagnosis:  Obstruction  of  small  bowel 
(Fig.  396).  The  colon,  examined  by  clysma,  shows  a  redundant  sig- 
moid; the  appendix  is  visible.  Otherwise  negative  (Fig.  397).  Find- 
ings at  operation:  Localized  hypertrophic  tuberculosis  involving  10 
inches  of  the  jejunum,  about  6  feet  from  its  origin.  Considerable 
involvement  of  mesentery.  Obstruction  of  the  bowel  is  marked,  the 
canal  being  cicatricial  and  filled  with  granulation  tissue.  Above  the 
obstruction  the  bowel  is  enormously  distended.  Operation:  Resec- 
tion 12  inches  of  jejunum;  lateral  anastomosis.  A  photograph  of  the 
pathologic  specimen  is  shown  in  Fig.  398. 


432       MISCELLANEOUS    LESIONS    OE   THE    SMALL   INTESTINE 

Case  120,591,  man,  aged  60  years.  Nine  months  ago  he  first 
noticed  loss  of  appetite  and  occasional  slight  cramping  pain  in  abdo- 
men. Later  he  began  to  have  spells  of  vomiting,  usually  at  night. 
The  vomitus  was  light-colored  and  watery,  as  a  rule,  but  on  one  occa- 
sion it  was  cherry-colored,  and  at  another  time  dark  and  foul-smelling. 


Fig.  401. — Case  86,605. 


Fig.  403. — Case  86.605. 


The  vomiting  came  at  intervals  of  eight  or  ten  days,  was  preceded  by 
constipation,  and  followed  by  diarrhea.  At  present  his  appetite  is 
fair  and  food  seems  to  agree,  but  he  has  some  epigastric  discomfort. 
Weight  loss,  30  pounds.  No  masses  palpated;  rectal  shelf  free. 
Roentgen  findings:  Obstruction  at  ileocecal  valve  (Fig.  399).  (No 
examination  of  colon  by  clysma.)     Findings  at  operation:  Extensive 


REPORT    OF    CASES  433 

carcinoma  involving  cecum,  ascending  colon  and  portion  of  transverse 
colon.  Operation:  Resection  of  10  inches  of  the  ileum,  cecum,  ascend- 
ing colon  and  one-half  of  the  transverse  colon.  Lateral  anastomosis. 
Pathologist's  report:  Carcinoma.     No  glandular  involvement  found. 

Case  85,886,  man,  aged  43  years.  Ten  months  ago  he  had  an 
attack  of  cramping  pain,  three  or  four  hours  after  a  meal,  which  was 
relieved  only  by  induced  vomiting.  Six  weeks  later  he  had  a  similar 
attack  and  later  others,  at  intervals  of  three  or  four  weeks.  For 
four  months  the  trouble  has  been  practically  continuous.  Pain  comes 
an  hour  and  a  half  or  more  after  eating  and  is  not  reheved  until  he 
induces  vomiting.  He  frequently  brings  up  bile  and  large  quantities 
of  foul  material.  Recently  he  has  resorted  to  lavage  and  he  is  some- 
times able  to  retain  small  amounts  of  fluid  and  soft  food.  Former 
weight  168;  present  114.  Gastric  analysis:  Total  acidity  50;  free  40; 
combined  10;  food  remnants.  Small  floating  mass  palpable  to  right  of 
umbilicus.  Roentgen  findings:  Although  the  examiner,  who  was 
at  that  time  inexperienced,  made  a  diagnosis  of  gastric  cancer,  the 
roentgenogram  (Fig.  400)  shows  the  typical  signs  of  obstruction  of  the 
small  bowel.  The  intestine  is  enormously  distended  and  deforms  the 
stomach  by  pressure.  The  markings  of  the  valvulse  connive ntes  are 
clearly  visible  in  the  gas  and  fluid  distended  bowel.  Findings  at 
operation :  Ring  carcinoma,  upper  small  intestine.  Metastatic  nodules 
in  omentum.  Operation:  Enteranastomosis  between  distended  and 
collapsed  loop  of  bowel. 

Case  86,605,  man,  aged  57  years.  Following  an  attack  of  diarrhea 
nine  months  ago,  the  patient  lost  appetite  and  began  to  vomit  occasion- 
ally two  or  three  hours  p.c.  The  vomiting  is  preceded  by  soreness 
at  the  right  costal  margin.  During  the  past  week  he  has  been 
worse'  with  epigastric  distress  several  hours  p.c,  followed  by  vomit- 
ing of  sour,  bitter  fluid.  Never  food-ease.  Usual  weight  150;Jnow 
132.  Total  acidity  48;  free  40;  combined  8;  food  remnants;  sarcines. 
Movable,  tender  mass  low  in  the  right  epigastrium.  Roentgen 
findings:  Gastric  retention  of  half  the  six-hour  meal.  Retention 
also  in  duodenum  and  loop  of  upper  small  bowel,  which  latter  is  high 
up  behind  stomach,  and  shows  a  collection  of  gas  at  point  of  obstruc- 
tion (Fig.  401).  After  filling  the  stomach  the  collection  of  bariiun  in 
the  small  bowel  was  obliterated  in  the  gastric  shadow  (Fig.  402) .  The 
gas-bubble  at  the  point  of  obstruction  could  still  be  seen.  Findings 
at  operation:  Spool  carcinoma  upper  jejunmn,  lumen  the  size  of  a 
lead  pencil.  Operation:  Resection  upper  jejunum,  end  to  end  anas- 
tomosis by  suture.  Jejunostomy  for  feeding.  Pathologist's  report: 
Carcinoma.     Glands  inflammatory.     Pathologic  specimen,  Fig.  403. 

28 


CHAPTER  XXI 
THE  LARGE  INTESTINE 

Technic. — In  the  examination  of  the  colon  either  the  ingested 
meal  or  the  clysma,  or  both,  may  be  employed.  Of  the  two, 
the  clysma  is  the  more  important  and  the  more  commonly  used, 
although  the  meal  is  indicated  when  the  determination  of 
motility  is  chiefly  desired  and  when  stenotic  conditions  com- 
pletely obstruct  the  enema,  which  thus  fails  to  show  the 
proximal  hmits  of  an  obstruction. 

A  convenient  meal  is  a  cereal  with  barium,  such  as  is  used 
in  the  examination  of  the  stomach.  When  motility  (stasis, 
etc.)  is  to  be  investigated  especially,  the  meal  should  be  given 
without  previous  purgation  and  the  patient  should  continue 
his  usual  habits  as  to  eating  and  exercise  in  order  that  the 
customary  conditions  may  be  maintained.  Four  to  six  hours 
after  ingestion,  with  normal  motility  of  the  stomach  and  small 
bowel,  the  meal  will  begin  to  enter  the  cecum  and  the  examina- 
tion may  be  commenced.  The  combined  screen  and  plate 
examination  is  preferred,  and  should  be  repeated  at  set  intervals 
until  the  raeal  is  evacuated. 

When  the  clysma  is  to  be  employed,  preliminary  preparation 
of  the  patient  is  necessary.  He  should  take  1  or  2  ounces  of 
castor  oil  on  the  evening  prior  to  examination,  should  abstain 
from  the  evening  meal,  and  should  clear  out  the  bowel  with 
a  plain  or  soapsuds  enema  next  morning  before  coming  for 
the  test.  He  may  take  a  light  breakfast  if  desired.  The  vehicle 
for  the  opaque  clysma  may  be  fermented  milk,  potato-starch 
pap,  mucilage  of  acacia  or  some  similar  medium,  and  either 
barium  or  bismuth  may  be  used.  The  clysma  which  we'  are 
accustomed  to  use  is  prepared  by  stirring  8  ounces  of  barium' sul- 

434 


TECHNIC  435 

phate  into  16  fluid  ounces  of  mucilage  of  acacia  and  adding  to  this 
the  contents  of  two  or  three  cans  of  semi-condensed  milk  so  as 
to  make  a  total  of  50  or  60  fluid  ounces.  Occasionally  this 
mixture  will  be  rather  too  thick  to  flow  freely  and  may  be  thinned 
with  a  little  water.  The  consistency  should  be  that  of  a  heavy 
cream.  The  clysma  should  be  warmed  to  about  body-tempera- 
ture for  use.  The  enema-container,  preferable  of  enameled 
ware,  should  be  attached  to  a  rope  running  over  an  elevated 
pulley,  so  that  it  may  be  raised  and  lowered  as  desired.  The 
rubber  inflow  tube  should  be  8  or  10  feet  long,  equipped  with  a 
spring-clip  cut-off,  and  tipped  with  a  self -retaining  syringe-noz- 
zle having  a  large  opening.  The  air  should  be  driven  out  of  the 
tube  by  permitting  the  enema  to  flow  for  a  moment  before  intro- 
ducing it  into  the  bowel.  It  may  be  mentioned  that  the  so-called 
high  enema  tube  is  quite  unnecessary  for  filling  the  bowel;  it  sim- 
ply curls  up  in  the  ampulla  without  entering  farther. 

-The  patient,  stripped  to  his  hips,  lies  on  his  back  on  the 
screen-table.  The  tip  of  the  inflow  tube,  anointed  with  vase- 
line, is  introduced  into  his  rectum.  When  all  is  ready,  the  room- 
lights  are  turned  out  and  the  spring-clip  is  released.  As  a  rule, 
the  enema  rather  slowly  fills  the  ampulla,  which  expands  to 
accommodate  its  increasing  contents.  Throughout  the  bowel 
the  filling  process  is  not  usually  seen  as  a  steady  advance  of  the 
clysma,  but  is  rather  irregular;  a  section  of  the  bowel  is  invaded 
by  a  tongue  of  the  oncoming  stream  and  then  filled  out  to  its 
capacity,  after  which  another  tongue  is  pushed  forward.  Fre- 
quently there  is  a  little  delay,  real  or  apparent,  at  the  flexures. 
After  a  flexure  is  passed,  the  proximal  portion  of  the  bowel 
may  fill  rapidly.  Complete  filling  will  ordinarily  take  place 
in  from  three  to  ten  minutes.  In  most  instances  some  of  the 
enema  will  pass  beyond  the  ileocecal  valve  into  the  ileum.  If 
the  patient  complains  of  pain  at  any  time,  the  spring-clip  may 
be  closed  or  the  container  lowered  until  the  discomfort  ceases. 
The  container  at  a  height  of  3  or  4  feet  above  the  patient  is 
usually  practicable. 

While  the  colon  is  filling,  the  screen  observation  should  be 


436  THE    LARGE    INTESTINE 

made  either  continuously  or  at  frequently  repeated  intervals. 
Palpatory  manipulation  is  quite  essential  in  the  investigation 
of  eccentric  appearances.  If  the  patient's  abdomen  be  rigid, 
it  may  be  relaxed  by  having  him  flex  his  thighs  and  breathe 
with  his  mouth  open.  The  tube  and  screen  should  be  shifted 
about  so  that  the  particular  region  to  be  inspected  will  be  in 
direct  line  with  them,  thus  avoiding  distortion  of  the  shadow. 
Turning  the  patient  to  one  side  will  change  the  angle  of  the 
rays  and  help  in  the  study  of  apparent  kinks  and  angulations. 
The  diaphragm  should  be  adjusted  from  time  to  time  to  permit 
close  inspection  of  suspicious  localities. 

Plates,  14  by  17,  are  best  made  with  the  intensifying  screen 
during  suspended  respiration.  The  lower  edge  of  the  cassette 
should  project  an  inch  or  two  below  the  plane  of  the  pubic 
arch.  The  tube-distance  should  be  from  20  to  30  inches.  At 
least  two  of  the  plates  should  be  made  with  the  patient  in  the 
dorsal  position,  and  others  with  the  patient  prone.  Both 
screening  and  plating  with  the  patient  standing  may  occasion- 
ally be  advantageous  to  show  changes  of  position.  When 
plates  only  are  desired,  it  is  more  convenient  to  give  the  enema 
with  the  patient  lying  on  either  side,  with  his  knees  drawn 
up,  rather  than  on  his  back.  The  old  time  knee-chest  and 
Trendelenburg  postures  are  awkward,  embarrassing  and 
unnecessary. 

When  the  examination  is  completed,  the  patient  may  go  to 
a  closet  and  empty  the  bowel.  Haenisch^  withdraws  the  enema 
through  the  tube  to  prevent  subsequent  difficulty  of  evacuation, 
but  in  our  experience  very  few  patients  have  had  annoyance  in 
this  respect.  For  several  hours  after  a  proctoscopic  examina- 
tion, a  patient  may  have  difficulty  in  retaining  the  enema  during 
the  roentgen  examination.  In  these  instances  it  is  better  not 
to  undertake  the  latter  examination  until  the  following  day. 

THE  NORMAL  COLON 

Like  normal  stomachs,  normal  colons  have  by  no  means  a 
constant  appearance  as  seen  in  the  radiologic  picture.     Colons 


POSITION  437 

which  functionate  properly  and  which  are  proved  to  be  without 
lesions  by  exploration  often  show  widely  diverse  roentgenologic 
characteristics,  especially  to  casual  view.  A  description  of  the 
normal  colon  must  therefore  be  limited  to  certain  common 
types  and  a  few  fundamental  points  of  similarity,  with  a  liberal 
allowance  for  exceptions.  Broadest  at  the  cecum,  where  it  is 
often  a  handsbreadth,  one  common  type  of  adult  colon  narrows 
slightly  but  progressively  to  the  sigmoid  flexure,  from  which  it 
opens  into  the  expansible  ampulla.  From  the  ampulla  descends 
the  tapering,  rectal  pouch.  The  apparent  diameters  depend 
largely  upon  the  degree  of  distention,  but  with  a  50-ounce 
clysma  the  descending  colon  and  sigmoid  appear  to  be  one- 
third  to  one-half  the  breadth  of  the  cecum.  In  other  cases, 
the  disparity  between  the  broadest  and  the  narrowest  part  of 
the  colon  is  much  less  marked,  the  effect  perhaps  of  the  local  tone 
condition  at  the  moment.  Perfectly  normal  colons  are  also 
often  seen  in  which  the  diameter  is  practically  uniform  from 
the  cecum  to  the  splenic  flexure. 

Position. — Normal  variance  as  to  position  is  especially  note- 
worthy. Closely  fixed  only  at  the  hepatic  and  splenic  flexures 
and  at  the  rectum,  the  colon,  between  these  points,  has  con- 
siderable latitude  of  passive  movement.  The  position  as  seen 
at  any  single  examination  is  subject  to  modification  by  the  posi- 
tion of  the  patient,  whether  standing  or  reclining,  the  tonus  of 
the  colonic  musculature,  the  length  of  colon  between  fixed  points, 
and  perhaps  to  some  slight  extent  by  the  weight  of  the  colonic 
content.  Disparity  between  the  heights  of  the  splenic  and 
hepatic  flexures  is  usually  marked.  The  hepatic  flexure  is 
about  at  the  level  of  the  first  lumbar  vertebra,  an  inch  or  two 
above  the  iliac  crest  line,  while  the  splenic  flexure  is  close  up 
under  the  left  diaphragm.  Occasionally,  the  hepatic  flexure 
may  be  at  a  higher  or  lower  level,  but  the  splenic  flexure  is 
rarely  displaced  except  by  pathologic  causes.  The  cecum  is 
usually  in  the  right  iliac  fossa,  its  lower  border  level  with  the 
sacral  promontory,  but  it  may  lie  well  down  in  the  pelvis. 

By  reason  of  redundancies,  which  are  not  necessarily  patho- 


438  THE    LARGE    INTESTINE 

logic,  the  transverse  colon  and  sigmoid  flexure,  occasionally 
also  the  descending  colon,  may  be  so  looped  and  placed  as  to 
give  various  configurations.  A  long,  lax  transverse  colon  may 
sag  to  the  pelvis,  producing  imitations  of  various  letters  of  the 
alphabet.  The  sigmoid  flexure  is  especially  variable  in  length 
and  position.  When  long,  it  may  show  as  a  tangled  festoon, 
or  a  single  long  loop  may  ascend  well  up  out  of  the  pelvis.  The 
descending  colon  is  also  sometimes  long  and  looped  upon  itself. 
In  children,  the  colon  often  forms  an  oval,  the  transverse  colon 
being  high  and  arched,  and  without  any  clearly  marked  he- 
patic flexure.  Very  rarely  this  may  be  found  in  adults.  Hertz 
states  that  although  the  ascending  and  transverse  colon  of  the 
new-born  is  quite  short,  the  whole  length  of  the  colon  is  three 
times  the  length  of  the  infant,  due  to  the  relatively  excessive 
length  of  the  pelvic  colon. 

It  is  almost  superfluous  to  say  that  positions  and  configura- 
tions may  vary  at  successive  examinations,  and  the  picture  seen 
with  a  patient  standing  may  be  quite  different  from  that  seen 
when  he  is  recumbent  (Figs.  404,  405,  406,  407). 

Contour. — During  and  immediately  after  the  administra- 
tion of  the  enema,  the  colon,  while  somewhat  sinuous,  usually 
has  a  relatively  smooth  contour,  with  few  or  no  sharply  marked 
indentations  or  indefinite  shadings.  Soon  after  the  filling  process 
is  completed,  however,  with  the  institution  of  general  tonic 
contraction,  the  scalloped  appearance  due  to  haustration  is  seen. 
The  haustra  are  especially  emphasized  in  the  descending  and 
transverse  portions;  later  in  the  different  segments  of  the  bowel 
the  haustra  become  more  accentuated  or  relax  slowly  from  time 
to  time.  A  sharply  angular  indentation  of  the  cecum  is  com- 
monly seen  at  the  ileocolic  juncture  and  there  may  be  a  corre- 
sponding indrawing  opposite.  In  the  rectum  the  valves  of 
Houston  (Heister)  sometimes  produce  one  or  more  acute,  uni- 
lateral indentations.  As  seen  with  the  ingested  meal,  the 
haustral  sacculations  of  the  colon  are  much  more  emphatic  than 
with  the  enema,  and  the  barium  in  segments  between  haustra 
may  be  narrowed  to  a  thin  ribbon,  so  that  the  examiner  may  be 


CAPACITY 


439 


inclined  to  suspect  a  stenosis.  Usually  the  meal  does  not 
preserve  its  continuity  unbroken,  but  is  separated  into  detached 
portions. 


Fig.  406.  Fig.  407. 

Figs.  404,  405,  406,  407.— Normal  colons. 

Capacity. — The  capacity  of  the  adult  colon  depends  not  only 
upon  its  length,  but  also  upon  the  tone  of  its  musculature.  The 
amount  required  to  fill  it  within  the  hmit  of  comfort  ranges 


440  THE    LARGE    INTESTINE 

ordinarily  from  40  to  60  fluid  ounces.  When  it  is  hypertonic 
and  spastic,  a  much  smaller  quantity  will  visualize  it  throughout 
than  when  it  is  relaxed  and  atonic. 

Mobility. — An  important  feature  of  the  normal  colon  is  its 
mobility  by  palpatory  manipulation  excepting  at  its  three 
points  of  fixation,  although  even  the  hepatic  flexure  is  ordinarily 
susceptible  of  slight  shifting.  The  splenic  flexure  is  not  only 
fixed  by  its  suspensory  ligament,  but  is  also  sheltered  from  pal- 
pation bj^  the  thoracic  cage.  The  lower  sigmoid,  protected  by 
the  pelvis,  cannot  be  easily  shifted  about.  In  women,  gyneco- 
logic palpation  may  be  of  service.  A  tense  abdominal  wall 
greatly  hinders  manipulation  of  the  colon  and  this  feature  must 
be  duly  considered. 

Peristalsis. — Although  numerous  studies  of  the  peristaltic 
movements  of  the  colon  have  been  made,  the  conclusions  drawn 
have  been  somewhat  contradictory,  and  this  function  is  not  as 
yet  well  understood.  One  feature  of  peristaltic  activity  which, 
though  rarely  seen  directly'',  has  been  generally  accepted,  is  a 
rapid  propulsive  movement  en  masse  of  a  large  portion  of  the 
colonic  content,  occurring  at  infrequent  intervals.  The  rarity 
of  its  observation  is  shown  by  the  fact  that  Holzknecht,^  who 
first  noted  it,  saw  it  but  twice  in  1000  cases  examined  for  five 
to  fifteen  minutes.  The  movement  occupied  only  a  few  seconds 
of  time,  and  Holzknecht  was  at  first  of  the  opinion  that  it  oc- 
curred only  about  three  times  in  twenty-four  hours,  although  he 
has  later  come  to  the  belief  that  it  occurs  oftener,  perhaps  six 
or  eight  times  daily.  In  the  cases  which  he  saw,  about  one-third 
of  the  contents  was  suddenly  driven  forward  a  distance  equal  to 
its  own  length .  Similar  findings  have  been  made  by  others  and 
an  analysis  of  the  movement  has  been  attempted.  Jordan^  has 
noted  that  when  a  wave  starts,  the  part  in  front  loses  its  haustral 
sacculation,  becoming  smaller  but  smooth  by  toning  up  of  the 
muscular  fibers.  The  advancing  wave  consists  of  a  very  firm 
contraction  of  the  circular  fibers,  each  fiber  contracting  in  its 
turn  and  remaining  strongly  constricted  for  many  minutes  after 
the  wave  has  passed.     The  rear  end  of  the  wave  is  sharply 


PEKISTALSIS  441 

conical.  It  is  stimulated  by  the  taking  of  meals,  by  defecation, 
irritation  (colitis)  and  emotion.  Schwarz'*  holds  that  it  may  be 
excited  by  the  discharge  of  a  large  quantity  of  chyme  into  the 
colon  as  the  result  of  increased  gastric  and  intestinal  peristalsis. 
The  wave  is  more  or  less  perceptible  subjectively.  He  believes 
that  the  segment  in  front  of  the  wave  is  not  contracted,  but  is 
dilated. 

Other  than  this  passive  movement,  which  has  been  seen 
infrequently,  but  definitely,  observers  have  described  a  variety 
of  minor  peristaltic  phenomena.     Haustral  segmentation,  which 
Holzknecht  claims  has  nothing  to  do  with  peristalsis  except  to 
retard  it,  complicates  the  matter.     However,  Rieder  concluded 
from  plate  studies  that  there  are  four  kinds  of  movements: 
Peristalsis,  antiperistalsis,  oscillating  movements,  and  uniform 
tonic  contractions.     Schwarz,-^  examining  after  an  ingested  meal, 
observed  a  rocking  back  and  forth,  mixing  movement  (wiege- 
phanomen)  and  regular  rapid  constrictions.     Interval  examina- 
tions every  three  to  five  minutes  showed  alterations  of  contour 
which  were  greatest  in  the  cecum  and  ascending  colon  and  grew 
progressively    less    marked,  distalward.     The    waves    he    saw 
traveled  both  oralward  and  analward  from  a  fixed  point,  making 
a   flattened    depression    lengthening   in    each    direction.     This 
peculiarity  of  the  wave  perhaps  accounts  for  the  frequent  ob- 
servations of  antiperistalsis  by  others.     Conceding  its  existence, 
it  must  not  be  classed  with  gastric  antiperistalsis,  which  latter 
is   seen   as   a   strictly   pathologic   manifestation.     As   to   this, 
Schwarz^  says:     '^At  this  point  I  may  advert  to  the  oft-recur- 
ring question  as  to  the  presence  of  antiperistalsis  in  the  colon. 
Whether  the  retrograde  transport  results  from  an  actual  anti- 
peristalsis or  rather  from  a  passive  backflow  behind  a  forward 
advancing  constriction-wave  cannot  be  decided  without  further 
data.     In  my  opinion  the  retrograde  transport  in  the  colon  is 
most  commonly  the  result  of  a  passive  backflow,  brought  about 
by  a  hindrance  to  the  progressing  mass,  whether  this  hindrance 
be   a  strongly   contracted,   filled,   gas-distended  or  organically 
stenosed  portion  of  the  intestine.     One  has  only  to  recall  how 


442  THE    LARGE    INTESTINE 

in  an  esophageal  stenosis,  with  waves  going  toward  the  cardia, 
the  food-mass  is  forced  upward.  I  have  already  pointed  out 
that  active  small  moA^ements  can  shove  the  intestinal  content 
backward  when  there  is  a  lessened  tonus  in  this  direction.  The 
rocking  back  and  forth  after  a  clysma  is  apparently  not  due  to 
an  antiperistalsis,  but  a  backswing  from  powerful,  broad,  for- 
ward-going contractures.  In  this  I  am  of  one  view  with  v. 
Bergmann  and  Lenz.  However,  on  one  occasion  with  the  enema 
I  was  able  to  see  indubitable  antiperistaltic  action  in  the 
colon.  Anj'^^ay,  discussion  as  to  whether  there  is  antiperistalsis 
or  not  has  no  very  great  significance.  Certain  is  it  that  retro- 
grade stool-movements  occur  in  the  colon,  and  take  place 
normally.     With  this  we  must  at  present  be  contented." 

Barclay'  has  twice  seen  massive  movements,  but  he  is  frankly 
skeptical  as  to  the  lesser  waves.  He  saj^s:  ''It  is  evident  that 
the  slow  peristalsis  which  used  to  be  described  never  takes  place 
— at  any  rate,  we  never  see  it — and  the  only  change  we  do  see 
in  the  shadow  is  that  occasionally  a  small  bolus  rolls  from  one 
saccule  to  another  in  a  manner  that  is  more  suggestive  of  the 
action  of  gravity  than  of  the  normal  passage  of  feces." 

A  comparison  of  the  observed  movements  of  the  colon  with 
those  of  the  small  bowel  shows  similarities  which  are  not  sur- 
prising when  it  is  recalled  that  these  organs  are  not  wholly 
independent  but  parts  of  a  continuous  tube.  The  rhythmic 
segmentation  of  the  small  bowel  has  its  analogue  in  the  haustra- 
tion  of  the  colon,  and  both  apparently  have  two  forms  of  ortho- 
peristalsis — slow  and  rapid.  However,  in  the  course  of  a  routine 
examination,  the  observer  is  not  likely  to  see  any  peristaltic 
acti^dty  of  the  colon  at  all  comparable  to  that  of  the  stomach. 
By  close  study  of  the  screen-image  or  of  successive  plates,  he 
may  note  local  changes  of  contour,  but  he  will  seldom  be  able 
to  trace  the  progress  of  any  single  contraction. 

Motility. — The  normal  motility  of  the  colon  as  shown  by  the 
rate  of  progress  of  opaque  ingesta  through  it  is  hardly  subject 
to  exact  determination  because  of  the  numerous  varying  factors 
which  enter  into  the  matter.     Yet  an  attempt  at  this  determina- 


THE    ABNORMAL    COLON  443 

tion  may  be  of  value  provided  the  observer  interprets  his  findings 
hberally  and  without  strict  adherence  to  set  rules. 

Hertz^  suggests  the  following  as  an  average  time-table  for 
the  ''head"  of  the  ingested  meal: 

Cecum 4  hours 

Hepatic  flexure 6  hours 

Splenic  flexure 9  hours 

Pelvic  colon  (sigmoid) 12  hours 

From  this  point  on,  the  rate  of  progress  will  depend  upon  the 
time  and  frequency  of  stooling,  and  as  this  occurs  ordinarily 
once  daily,  a  twenty-four  hour  variation  is  easily  possible 
under  normal  conditions.  Twenty-four  to  forty-eight  hours  is 
regarded  by  many  roentgenologists  as  a  fair  time  basis  for  the 
passage  of  bariumized  food  through  the  digestive  tract.  This 
would  allow  twenty  to  forty-four  hours  for  its  journey  through 
the  colon;  but  these  figures  are  applicable  only  on  the  condition 
that  the  patient  has  not  been  subjected  to  recent  drug-action 
and  that  he  pursue  normal  and  accustomed  habits  as  to  eating, 
drinking,  exercise  and  stooling.  Nor  must  absolutely  complete 
evacuation  be  expected  within  two  days  or  even  longer.  Hold- 
ing^ has  remarked  that  the  fecal  current  is  like  any  other 
current;  the  center  moves  faster  than  the  sides,  and  remnants 
of  bismuth  are  seen  for  many  days  after  the  bulk  of  it  has  been 
expelled.  After  a  partial  evacuation,  the  remainder  of  the 
barium  or  bismuth  is  often  seen  irregularly  distributed  through 
the  bowel,  and  these  local  accumulations  are  not  necessarily 
indicative  of  obstruction  distal  to  them,  nor  of  functional 
impairment. 

THE  ABNORMAL  COLON 

Position. — Other  than  the  variations  of  position  which  may 
occur  normally,  definite  displacements  or  anomalies  of  situation 
are  sometimes  encountered.  In  association  with  general  visceral 
transposition,  situs  transversus  of  the  colon  is  occasionally  seen, 
the  cecum  and  ascending  colon  lying  on  the  left  side,  the  de- 
scending colon  on  the  right.     In   one  of  our  cases  the  colon 


444 


THE    LARGE    INTESTINE 


alone  was  transposed.     Most  radiographers  indicate  one  side 
of  the  plate  with  a  leaden  R  or  h,  or  habitually   apply   the 


Fig.  410.  Fig.  411. 

Figs.  408,  409,  410,  411. — Normal  colons. 

number  to  a  certain  side.     Carelessness  in  this  respect  might  be 
a  source  of  error  where  plates  only  are  made. 

Arrest  of  developmental  migration  may  result  in  a  high- 
placed  cecum,  or  the  entire  colon  may  still  lie  to  the  left  of  the 


POSITION 


445 


vertebral  column — so-called  non-rotation.  By  failure  of  the 
cecum  and  ascending  colon  to  rotate  on  their  long  axes,  the 
ileocolic  juncture  may  be  found  on  the  outer  aspect  of  the 
cecum,  instead  of  the  inner. 

Displacement  of  any  part  of  the  colon  may  be  produced  by 
extrinsic  tumors  of  every  sort,  including  those  of  the  liver, 
kidney,  pancreas,  spleen,  uterus,  and  adnexse,  by  adhesion 
bands,   by  pregnancy  and  by  psoas  abscess.     Displacements 


Fig.  412. — Coloptosis. 

commonly  affect  only  those  portions  of  the  colon  which  are  more 
or  less  movable  normally,  the  hepatic  flexure  being  occasionally, 
and  the  splenic  flexure  rarely,  impUcated. 

Whatever  may  be  the  final  adjudication  of  the  much  mooted 
question  of  ptosis  and  its  importance,  it  can  hardly  be  doubted 
that  this  term  has  been  abused  in  connection  with  the  colon, 
and  especially  its  transverse  portion.  With  a  little  increase  of 
its  length,  the  transverse  colon  may  easily  have  its  middle 
portion  down  in  the  pelvic  basin,  whether  its  possessor  be 
asthenic  or  not,  and  to  label  this  condition  as  ptosis  is  certainly 


446  THE    LARGE    INTESTINE 

unfair.  On  the  other  hand,  there  may  be  marked,  evident  and 
actual  displacement  downward  of  the  colon,  and  the  position 
of  the  flexures  is  a  better  criterion  of  this  than  the  position  of 
the  transverse  colon.  The  hepatic  flexure  may  be  well  below 
the  ihac  crest  and  even  the  splenic  flexure  may  be  sUghtly  dropped, 
although  this  is  quite  uncommon.  In  decided  enteroptotics 
nearly  the  entire  colon  may  be  huddled  together  in  the  pehic 
basis  (Fig.  412).  In  judging  position,  apparent  displacement 
due  to  obliquity  of  the  rays  must  be  borne  in  mind. 

Contour. — Irregularities  of  contour — filhng-defects — may  be 
produced  by  intrinsic  tumors,  diverticuhtis,  or  bands  of  ad- 
hesions. Apparent  filling-defects  may  be  caused  by  fecal 
miatter,  fecaliths,  gas,  localized  spasm,  extrinsic  tumors,  insuflB.- 
cient  quantity  of  the  enema,  or  the  pressure  of  adjacent  bony 
parts  such  as  the  spine  and  pelvic  brim. 

The  coils  of  the  sigmoid  farthest  from  the  screen  or  plate 
often  seem  vaguely  shadowed.  ^Movement  of  the  patient  or 
shght  shifting  of  the  bowel  may  make  what  seem  to  be  fiUing- 
defects  on  the  plate. 

Sharp  angulation  may  be  due  to  actual  kinking;  more  often, 
however,  it  will  be  found  that  this  appearance  is  due  to  the  angle 
at  which  the  loop  is  viewed.  According  to  Jordan,"  the  points 
of  election  for  kinks  in  the  colon  are  the  hepatic  flexure,  the 
proximal  portion  of  the  transverse  colon,  and  the  sigmoid. 
Hertz ^^  has  seen  but  one  case  of  kinking  with  partial  obstruc- 
tion and  this  was  located  at  the  splenic  flexure.  He  also  cites 
a  case  of  Frank's  in  which  a  mobile  left  kidney  adherent  to  the 
splenic  flexure  caused  a  kink  of  the  latter. 

Mobility. — Abnormally  increased  mobility  of  the  cecum  and 
ascending  colon  has  been  noted  in  the  cecum  inohile  et  atonicum 
of  Wilms  in  association  with  tenderness  and  dilatation.  With 
increased  length  of  any  segment  between  suspension  points, 
there  is  a  corresponding  increase  of  its  mobihty. 

Diminished  mobility  even  to  complete  fixation  is  a  common 
sequence  of  adhesion-producing  pericohc  inflammations.  More 
or  less  fixation  of  the  cecum  may  be  the  result  of  appendicitis, 


PEKISTALSIS  •  447 

tuberculosis,  pelvic  conditions  or  malignancy.  In  cases  of 
so-called  Jackson's  membrane,  the  proximal  half  of  the  trans- 
verse colon  has  been  found  ptosed  and  parallel  with  the  ascend- 
ing colon  and  inseparable  from  it.  Adhesions  from  a  peri- 
cholecystitis or  a  perforating  duodenal  ulcer  may  more  firmly 
anchor  the  hepatic  flexure  or  attach  it  to  the  pyloric  end  of  the 
stomach.  Carcinoma  of  any  part  of  the  bowel,  whether 
primarily  intrinsic  or  extrinsic,  may  fix  it.  The  sigmoid  flexure 
may  be  fixed  by  pelvic  inflammations  of  any  sort. 

In  regard  to  adhesions  generally — and  this  applies  not  only 
to  the  colon  but  to  the  entire  gastro-intestinal  tract — it  may  be 
said  that  one  of  the  hardest  lessons  the  roentgenologist  has  to 
learn  is  that  juxtaposition  of  the  viscera  does  not  necessarily 
mean  that  they  are  adherent  to  each  other,  but,  on  the  contrary, 
are  rarely  so.  In  repeated  instances,  when  we  suspected  ad- 
hesions, or  when  the  diagnosis  of  adhesions  had  been  made  by 
others,  surgical  exploration  has  shown  either  no  trace  of  them, 
or,  if  found,  they  were  not  where  they  were  surmised  to  be. 
The  diagnosis  of  adhesions  or  their  emphasis  in  a  roentgenologic 
report,  is  not,  as  a  rule,  highly  appreciated  by  the  surgeon  or 
internist.  Both  are  likely  to  feel  that  a  serious  pathologic 
process  should  show  x-ray  evidence  other  than  adhesions,  and 
if  the  roentgen  examiner  finds  little  or  nothing  else,  he  lays 
himself  open  to  the  criticism  either  of  lacking  thoroughness  or 
of  avoiding  a  specific  diagnosis.  Cases  in  which  a  laparotomy 
has  been  done  previously,  often  show  adhesions — so  often  that 
their  roentgenologic  discovery  is  not  edifying  to  the  surgeon. 

Peristalsis. — Since  there  is  a  lack  of  definite  knowledge  as 
to  the  normal  peristalsis  of  the  colon  other  than  a  general  agree- 
ment that  forward  movements  en  masse  occur  at  infrequent 
intervals,  also  little  is  known  regarding  peristalsis  in  disease. 
Jordan  has  seen  increased  speed  of  the  massive  movement  and 
a  greater  distance  traversed  in  diarrhea  and  with  the  enema. 
Case^^  noted  "exaggeration  of  normal  antiperistalsis"  in  car- 
cinoma. Schwarz  has  observed  stenotic  hyperperistalsis  with 
carcinomatous  stricture  at  the  hepatic  flexure. 


448  THE    LARGE    INTESTINE 

Length  and  Diameter. — Increased  length  of  the  colon,  the 
redundancy  being  usually  most  marked  in  the  sigmoid  and 
transverse  portions,  is  a  relatively  common  finding  in  consti- 
pated persons.  Such  redundancies  are  also  found,  however, 
in  colons  which  functionate  normally.  Since  the  longitudinal 
muscle-fibers  are  largely  collected  into  the  tenia,  it  is  obvious 
that  the  tone  condition  of  the  tenia  has  much  to  do  with  the 
length  and  position  of  the  colon  at  a  given  moment.  Considered 
in  this  way,  it  may  be  that  so-called  redundancy  is  often  merely 
an  expression  of  atony.  Redundancy  of  the  sigmoid  with 
dilatation  (megasigmoid)  has  been  observed  occasionally.  In 
congenital  idiopathic  dilatation  of  the  colon  (Hirschsprung's 
disease)  the  immense  dilatation  throughout  is  strikingly  shown 
by  the  x-ray.  Dilatation  of  the  cecum,  ascending  and  trans- 
verse portions,  with  evident  loss  of  tone,  is  not  infrequently^ 
noted.  Dilatation  of  anj^  part  of  the  colon,  proximal  to  a 
stenosis,  may  be  evident.  Hypertonic  or  spastic  narrowing  of 
the  colon,  particularly  in  its  transverse,  descending  and  sigmoid 
portions,  is  noted  occasionally  in  cases  of  constipation,  but 
it  may  accompany  a  colitis  with  frequent  stools.  A  narrow 
unhaustrated  colon  is  often  seen  in  cases  of  granular  or  ulcerative 
colitis. 

Motility. — Hypermotility  of  the  colon  is  seen  typically  in 
association  with  non-obstructing  gastric  carcinoma,  in  which 
condition  the  head  of  the  meal  may  be  in  the  descending  colon 
or  even  the  ampulla  in  six  hours.  Hypermotility  with  similar 
but  usually  less  marked  advancement  is  also  seen  in  duodenal 
ulcer,  achylia  and  diarrheic  conditions.  Hypomotilrty  with 
decidedly  slow  progress  of  the  meal  through  the  colon,  may  be 
due  either  to  organic  obstruction  or  merely  to  functional  im- 
pairment. Retention  of  all  or  the  greater  part  of  the  meal  in  the 
colon  after  forty-eight  hours  may  be  regarded  as  possibly  signifi- 
cant of  obstruction  or  grave  functional  disturbance,  but  further 
conclusions  should  not  be  drawn  from  this  fact  alone. 


EEFERENCES  449 

REFERENCES 

1.  Haenisch,    G.    F. :  "The   Roentgen   Examination   of  the  Large 

Intestine."     Ar^ch.  Roentgen  Ray,  1912,  xvii,  208-15. 

2.  HoLZKNECHT,  G. :  "  Die  normal  Peristaltik  des  Colon."     Miinchen. 

Med.  Wchnschr.,  1911,  ii,  2401-3. 

3.  Jordan,  A.  C.:  "The  Peristalsis  of  the  Large  Intestine."     Arch. 

Roentgen  Ray,  1914,  xviii,  328-9. 

4.  ScHWARZ,  G. :  "ZuY  Physiologie  und  Pathologie  der  menschlichen 

Dickdarmbewegungen."     Miinchen.  Med.  Wchnschr.,  1911,  ii, 
1489-94. 

5.  ScHWARZ,  G.:  "Zm"  genaueren  Kentniss  der  grossen  Kolonbewe- 

gungen."     Miinchen.  Med.  Wchnschr.,  1911,  ii,  2060-63. 

6.  ScHWARZ,  G.:  "Klinische  Roentgendiagnostik  des  Dickdarms." 

1914,  Springer,  Berlin,  44  p. 

7.  Barclay,  A.  E. :  "Notes  on  the  Movements  of  the  Large  Intes- 

tine."    Arch.  Roentgen  Ray,  1912,  xvi,  422-24. 

8.  Hertz,  A.  F.:  "Investigations  of  the  Motor  Functions  of  the 

Alimentary  Canal  by  Means  of  the  X-rays."     Brit.  Med.  Jour., 
1912,  i,  225-29. 

9.  Holding,  A.:  "Observations  of  Cases  of  Constipation  by  Means 

of  the  Roentgen  Rays."     Am.  Quart.  Roentgenol.,  1911,  iii,  148- 
51. 

10.  Jordan,  A.  C:  "Radiography  in  Intestinal  Stasis."     Proc.  Roy. 

Soc.  Med.,  1911  (Elect.  Ther.  Section),  v,  9-37. 

11.  Hertz,    A.    F. :  "Constipation    and    Allied    Disorders."     1909, 

Frowde,  London,  110. 

12.  Case,  J.  T.:  "  The  Roentgenologic  Findings  in  Malignant  Obstruc- 

tion of  the  Colon."     Lancet-Clinic,  1914,  cxl,  216-19. 


29 


CHAPTER  XXII 
CANCER  OF  THE  COLON 

Precisely  as  in  cancer  of  the  stomach,  the  most  important 
sign  of  cancer  of  the  colon  is  the  filling-defect — a  local  irregu- 
larity of  contour  produced  by  jutting  of  the  growth  into  the 
intestinal  lumen,  by  contracture  of  the  infiltrated  wall,  and 
probably  also  to  some  extent  by  spasm  aroused  by  the  neoplasm. 
The  irregularity  may  be  rather  sharply  delineated,  but  is  more 
often  indefinitely  shaded. 

Next  in  importance  to  the  filling-defect  is  the  presence  of 
obstruction,  the  fact  of  which  is  alone  highly  significant,  since 
acquired  non-malignant  stricture  of  the  colon  is  exceedingly 
rare  (Hertz). ^  The  blocking  may  be  evidenced  by  an  accumu- 
lation and  delay  of  the  meal  proximal  to  the  stenosis,  and  by 
obstruction  to  the  enema.  It  is  noteworthy  that  the  inflow  of 
the  enema  is  sometimes  markedly  or  completely  obstructed, 
when  the  passage  of  the  meal  is  apparently  hindered  only  slightly 
or  not  at  all,  and  the  patient  gives  no  history  of  obstipation. 
This  is  probably  due  to  a  valve-like  effect  of  the  growth.  Dila- 
tation of  the  bowel  above  the  stricture  is  sometimes  remarked. 
To  these  signs  may  be  added  the  coincidence  of  a  palpable  tumor 
with  the  filling-defect  or  with  the  point  of  obstruction.  In  a 
few  reported  instances  an  exaggeration  of  peristaltic  activity 
was  noted  proximal  to  the  obstruction.  Extension  of  the  growth 
outside  the  bowel  may  occasionally  result  in  evident  fixation, 
but  more  often  the  normal  mobihty  of  the  intestine  is  not 
impaired. 

For  eliciting  signs  of  carcinoma,  the  combined  screen  and 
plate  examination  with  the  opaque  enema  is  usually  more  con- 
venient and  effective  than  examination  with  the  opaque  meal. 

450 


PSEUDO-FILLING    DEFECTS  451 

By  the  enema  the  entire  bowel  or  that  portion  distal  to  a  com- 
plete obstruction  is  visualized  throughout  at  a  single  examination; 
filling-defects  are  more  readily  discovered,  and  the  site  of  the  ob- 
struction quickly  determined.  Where  the  latter  is  extreme,  its 
proximal  limits  can  be  found  by  giving  an  opaque  meal. 

A  filling-defect  due  to  carcinoma  is  characterized  by  its 
irregularity,  its  constancy  upon  all  plates  and  at  successive 
examinations,  its  permanence  in  spite  of  palpatory  manipula- 
tion, and  its  persistence  after  the  administration  of  anti- 
spasmodics. Its  size  will  depend,  of  course,  upon  the  extent  of 
the  growth,  but  in  those  patients  whose  symptoms  are  at  all 
suspicious  the  lesion  will  nearly  always  be  found  of  demonstrable 
proportions. 

The  filling-defect  may  show  as  a  concentric  local  narrowing 
of  the  lumen  (napkin-ring  carcinoma)  or  it  may  be  unilateral. 
In  some  cases  with  marked  obstruction  the  enema  may  terminate 
with  a  bluntly  rounded,  smooth  contour  at  the  site  of  the 
stenosis,  while  in  others  more  or  less  tailing  out  may  be  seen. 

The  filling  defect  of  carcinoma  is  imitated  by  a  variety  of 
conditions.     Among  these  are : 

1.  Gas. 

2.  Insufficient  quantity  of  the  enema. 

3.  Fecal  matter. 

4.  Spasm. 

5.  Extrinsic  tumors. 

6.  Pressure  of  bony  parts. 

7.  Adhesions. 

8.  Diverticulitis,  tuberculosis  and  other  lesions  of  the 
intestine. 

Gas  collections  in  the  colon  are  relatively  common  and  they 
sometimes  produce  filling-defects  simulating  those  of  an  organic 
lesion.  When  gas  accumulations  are  present  they  wiU  usually 
be  found  in  the  proximal  portion  of  the  bowel,  most  often  in  the 
hepatic  flexure,  ascending  colon  or  cecum.  They  can  some- 
times be  displaced  by  palpation  during  the  screen-examination, 


452  CANCER    OF   THE    COLON 

may  have  a  varying  configuration  upon  successive  plates  and, 
as  a  rule,  the  outline  of  the  bowel  can  be  distinguished  (Fig. 
413). 

By  failure  to  give  a  sufficient  quantity  of  the  enema  the  bowel 
may  not  be  filled  throughout,  showing  patches  here  and  there 
resembhng  filling-defects.  The  patches  tend  to  shift  about  and 
are  not   very  deceptive.     By  lack  of  thorough  purgation  and 


Fig.  413. — Gas  in  the  colon  near  hepatic  flexure;  G,  imitating  the  filling  defect  of  cancer. 

cleansing,  fecal  matter  may  be  left  in  the  bowel  and  cause  filling- 
defects.  However,  with  the  routine  preparation  previously 
described,  this  rarely  occurs. 

Localized  spasm  of  the  colon  may  produce  most  vexing  imi- 
tations of  true  filling-defects.  Usually  the  affected  segment 
is  narrowed  and  shows  fine,  irregular  haustra.  Rarely,  the 
spasm  may  completely  obstruct  the  enema  at  the  point  in- 
volved. Figures  414  and  415  illustrate  marked  spasm  of  the 
transverse  colon,  a  duodenal  ulcer  being  found  at  operation. 
The  sigmoid  or  descending  colon,  occasionally  the  transverse, 


PSEUDO-FILLING    DEFECTS 


453 


Fig    414. — Obstruction  of  the  transverse  colon  at  (J,  by  ^pasm. 

pable  mass.     See  Fig.  415. 


No  corresponding  pal- 


FiG.  415. — Same  case  as  in  Fig.  414.  Colon  patent  after  belladonna  had  been 
given.  At  operation  a  duodenal  ulcer  was  found;  colon  negative.  No  roentgen  ex- 
amination of  the  stomach  and  duodenum  was  made  in  this  case. 


454 


CANCER    OF    THE    COLON 


is  sometimes  intensely  spastic  and  narrow,  and,  though  filled 
with  the  enema,  shows  small,  irregular  haustration  (Fig.  416). 
In  all  cases  where  spasm  is  suspected,  the  patient  should  be  given 
belladonna  to  physiologic  effect  and  the  examination  repeated. 

Extrinsic  tumors  by  the  thrust  of  their  outline  into  the  con- 
tour of  the  colon  may  rarely  produce  apparent  filling-defects, 
especially  in  fixed  portions  of  the  bowel.     As  a  rule,  however, 


Fig.  416. — Marked  spasticity  of  pelvic  colon,  S. 

such  tumors  do  not  alter  the  outline  of  the  colon  and  their 
extrinsic  situation  is  evident  upon  screen-examination. 

Pressure  of  the  spine  against  the  transverse  colon  may  cause 
a  seeming  defect  at  this  point,  and  a  small  apparent  defect  is 
often  seen  in  the  sigmoid  flexure  where  it  rises  over  the  brim  of 
the  true  pelvis,  but  such  defects  will  hardly  be  taken  seriously. 

Adhesions,  when  present,  are  usually  about  the  cecum  or 
pelvic  colon.  They  may,  but  rather  exceptionally,  cause  sharp 
irregular  serration  of  the  intestinal  border,  with  more  or  less 
fixajtion,  and  occasionally  may  obstruct  the  bowel. 


REPORT    OF    CASES  455 

Diverticulitis  of  the  sigmoid,  or  other  parts  of  the  colon,  by 
reason  of  the  accompanying  inflammatory  thickening,  may  pro- 
duce obstruction  and  filling-defects  resembling  those  of  cancer. 
When  the  characteristic  extra-lumenal,  barium-filled  diverticula 
can  be  discerned,  the  diagnosis  is  apparent,  but  sometimes  the 
sacculations  are  not  clearly  seen  as  such  and  roentgenologic 
distinction  from  cancer  is  impossible. 

Filling-defects  with  or  without  a  palpable  tumor  or  obstruc- 
tion, involving  the  cecum  and  ascending  colon,  should  not  be 
too  hastily  interpreted  as  cancer,  since  these  signs  may  be  pro- 
duced by  tuberculosis,  which  is  a  rather  frequent  lesion  in  this 
part  of  the  colon.  Purely  roentgenologic  differentiation  of  the 
two  conditions  cannot  be  made,  but  the  clinical  features  may  be 
decisive. 

An  extensive  appendiceal  abscess  may  distort  the  cecum  and 
ascending  colon  and  be  felt  as  a  mass.  Here  the  elementary 
clinical  facts  should  at  least  put  the  examiner  on  his  guard. 

Other  lesions  may  also  produce  filling-defects  or  obstruction, 
or  a  palpable  tumor,  and  thus  show  a  roentgenologic  similarity 
to  cancer.  Included  among  these  are  various  benign  tumors, 
polypi,  syphilis,  actinomycosis,  and  cicatricial  stricture  from 
ulcer.  These  lesions  are  all  relatively  infrequent.  Their 
differentiation  from  cancer  of  the  bowel  would  require  careful 
weighing  of  all  the  facts,  both  clinical  and  roentgenologic. 

Case  86,304,  female  aged  53  years.  For  thirty  years  she  has  had 
hemorrhages  from  the  bowel  intermittently.  These  have  been  less 
frequent  during  the  past  two  years.  A  year  ago  she  had  a  dysentery 
with  very  frequent  stools  which  at  times  showed  bright  red  blood. 
Since  then  she  has  had  diarrhea,  off  and  on.  Dm'ing  the  past  few 
months  she  has  had  pain  under  the  left  costal  margin  in  the  axillary 
line.  Her  bowels  are  always  loose,  with  much  gas  and  distress. 
Weight  loss,  45  pounds  in  one  year.  Marked  prolapse  of  anus  and 
internal  hemorrhoids.  Hemoglobin  65.  Wassermann  negative. 
Roentgen  findings:  Annular  filhng-defect,  with  extreme  narrowing  of 
lumen  in  descending  colon  near  splenic  flexure  (Fig.  417).  Notwith- 
standing the  great  local  narrowing,  the  entire  bowel  filled  readily  with 
the  enema  and  without  complaint  on  the  part  of  the  patient.     Findings 


456 


CANCER    OF    THE    COLON 


Fig.  417. — Case  86,304.     Napkin-ring    carcinoma  of  colon.     Filling  defect  and    nar- 
rowing, F.  D.     Photograph  of  specimen  Fig.  417o. 


Fig.  417a. — Case  86,304.     Photograph  of  specimen. 


REPORT    OF    CASES 


457 


at  operation:  Napkin-ring  carcinoma,  splenic  flexure  of  colon,  deeply 
situated  and  very  adherent.  Some  glandular  involvement.  Opera- 
tion: Exsection  (Mikulicz).  Pathologist's  report:  Carcinoma  (Photo- 
graph of  specimen,  Fig.  417a). 

Case  130,337,  female  aged  40  years.  Chronic  diarrhea  for  six 
years,  with  four  to  six  watery  stools  daily,  and  cramping  abdominal 
pain.  With  this  there  has  been  a  slowly  progressive  weakness.  Weight 
loss,  12  pounds.  Nodular,  tender  mass,  right  abdomen,  below  costal 
margin.  Free  fluid  in  abdomen;  ankles  swollen.  Hemoglobin  30. 
Stools  show  endameba  histolytica.     Roentgen  findings:  Gross  filling- 


FiG.  418. 


Case  130,337.     Carcinoma  of   the  right  half  of   the  transverse  colon. 
Filling  defect,  F.  D. 


defect,  transverse  colon,  near  hepatic  flexure,  corresponding  to  a  pal- 
pable mass  (Fig.  418).  Findings  at  operation:  Large  carcinomatous 
tumor  of  hepatic  flexure,  the  size  of  a  grapefruit.  Second  tumor, 
middle  of  transverse  colon,  adherent  to  gall-bladder.  Ileum  adherent 
to  tumor.  Operation:  (1)  Resection  cecum,  ascending  colon,  hepatic 
flexure  and  three-fifths  of  transverse  colon.  Murphy  button  anas- 
tomosis, end  to  side.  Cholecystectomy.  Pathologist's  report:  (1) 
Tumor  of  hepatic  flexure,  carcinoma.  (2)  Small  tumor  of  transverse, 
inflammatory,  (3)  No  glandular  involvement.  (4)  Catarrhal 
cholecystitis. 


458  CANCER    OF    THE    COLON 

Case  157,410,  male,  aged  31  years.  Since  an  attack  of  grippe  more 
than  two  years  ago  he  has  not  been  entirely  well.  About  a  year  ago 
he  noticed  jaundice,  itching  of  skin  and  progressive  weakness.  Five 
months  ago  he  had  a  chill,  high  fever,  severe  pain  in  lower  abdomen, 
nausea  and  vomiting.  He  was  in  a  hospital  for  three  weeks,  and  was 
told  that  he  had  "peritonitis  caused  by  rupture  of  the  intestine." 
After  leaving  the  hospital  he  gained  in  weight  on  a  selected  diet,  but 
had  a  continuous  dull  ache  and  occasional  sharp  pain  in  the  lower 
abdomen.  Bowels  regular,  with  cathartics.  In  the  past  month  he  has 
had  more  abdominal  soreness  and  has  grown  weaker.  He  thinks  that 
he  may  have  passed  very  small  amounts  of  dark  blood  in  the  stools. 
Weight  loss,  22  pounds  in  five  months.  Firm,  irregular  tumor  in  cecal 
region.  Lower  abdomen  tense  and  distended.  Probably  some  ascites. 
Rectal  shelf  apparently  free.  Hemoglobin  35.  Roentgen-ray  of  chest 
negative.  No  local  reaction  to  tuberculin  subcutaneously.  Roentgen 
findings:  Annular  filling-defect  of  ascending  colon  corresponding  to  pal- 
pable mass  (Fig.  419).  Findings  at  exploration:  Large  tumor  of  cecum 
and  ascending  colon,  adherent  over  large  surface  of  parietal  perito- 
neum. Nodules  extending  into  peritoneum  and  mesentery.  Specimen 
excised  for  microscopic  examination.  Radical  operation  not  indicated 
on  account  of  extent.     Pathologist's  report:  Adenocarcinoma. 

Case  146,918,  male,  aged  54  years.  Ten  weeks  ago  he  began  to  have 
diarrhea  with  four  or  five  stools  daily  and  colicky  pain.  The  pain  has 
subsided  but  he  still  has  tenderness  in  the  left  lower  abdomen.  For  a 
week  he  has  been  using  saline  enemata  daily  and  the  diarrhea  has 
lessened,  but  there  is  still  tenesmus  and  frequent  desire  to  stool,  with 
scant  results.  He  has  passed  blood  several  times  after  stooling  during 
the  past  two  weeks.  No  weight  loss.  Hemoglobin  88.  Tender 
movable  mass,  size  of  an  egg,  in  left  abdomen  at  level  of  iliac  crest. 
Complete  fistula  in  ano.  Roentgen  findings:  The  roentgenogram 
shows  two  filling-defects;  one  low  in  the  descending  colon,  the  other  in 
the  sigmoid  (Fig.  420).  Findings  at  operation:  Double  carcinoma; 
one  of  napkin-ring  type  in  descending  colon;  the  other  in  the  sigmoid. 
Operation:  Mikulicz.     Pathologist's  report:  Carcinoma. 

Case  107,182,  female,  aged  44  years.  Notwithstanding  a  good 
appetite  and  maintenance  of  weight  the  patient  has  not  been  well  for  a 
year,  complaining  chiefly  of  nervousness  and  insomnia.  A  month  ago 
she  began  to  have  attacks  of  epigastric  pain  becoming  general  over  the 
abdomen,  followed  by  a  loose  watery  stool  and  relief.  She  may  have 
two  or  three  of  these  attacks  daily;  no  relation  to  meals.  To-day,  for 
the  first  time  she  noticed  a  few  streaks  of  bright  blood  in  the  stool. 
Until  a  month  ago  she  was  always  constipated;  now  has  two  passages 


REPORT    OF    CASES 


459 


Fig.   419. — Case  157,410.     Filling  defect,  ascending  colon,  F.  D.     Annular  carcinoma. 

Appendix  visible,  A. 


Fig.  420. — Case   146,918.     Filling   defect  low  in   the   descending    colon,   also  in  the 

sigmoid,  F.  D. 


460 


CANCER    OF    THE    COLON 


Fig.  421.— Case  107,182.     Filling  defect  of  cecum,  F.  D.     Carcinoma. 


Fig.  422.— Case  144,665.     Filling  defect  of  cancer,  F..,:D. 


REPORT    OF    CASES 


461 


Fig.  423.— Case  80,026.     Obstruction  to  enema  at  0. 


Fig.  424. — Case  80,026.     Roentgenogram  after  ingested  meal.     Filling  defect,  F.  D. 


462 


CANCER    OF    THE    COLON 


daily.  At  an  examination  two  weeks  ago,  elsewhere,  a  mass  was 
found  in  the  right  abdomen.  Weight  loss,  18  pounds  in  one  and  a 
half  years.  Hemoglobin  60.  Tumor  in  cecal  region,  size  of  a  goose- 
egg,  rather  fixed.     Roentgen  findings:  Filling-defect  of  cecum  corre- 


FiG.  427 


Fig.  428. 
Figs.  425,  426,  427,  428. — Cancer  of  colon,  producing  either  obstruction,  O,  or 
a  filling  defect,  F.  D.,  or  both. 

sponding  to  a  palpable  mass  (Fig.  421).  Findings  at  operation: 
Carcinoma  of  ileocecal  coil  and  ascending  colon.  Large  tumors  in 
mesentery  of  small  intestine  along  spine.  Free  fluid.  Liver  not  in- 
volved.    Operation:  Ileocolostomy. 

Case  144,665,  female,  aged  44  years.     Up  to  ten  months  ago  she  was 


EEPORT    OF    CASES 


463 


in  general  good  health,  but  since  then  she  has  had  no  appetite  and  has  a 
little  discomfort  from  gas  three  or  four  hours  after  meals.  During  the 
past  two  or  three  months  her  bowels  have  been  loose,  with  three  or 


Fig.  429. 


Fig.  430. 


Fig.  431.  Fig.  432. 

Figs.  429,  430,  431,  432. — Cancer  of  colon,  some  showing  only   obstruction,  O, 

others  a  filling  detect  F.  D. 

four  stools  daily,  and  these  have  occasionally  show^n  small  clots  of  dark 
blood.  She  has  an  indefinite  ache  in  the  lower  abdomen  which  she 
thinks  is  of  ovarian  origin.  General  strength  poor.  Weight  loss,  15 
pounds  in   nine   months.     Hemoglobin   35.     Wassermann   negative. 


464 


CANCEE    OF    THE    COLON 


Abdomen  hard  and  resistant  throughout,  especially  lower  right,  where 
an  irregular  hard  mass  can  be  felt.  Pelvis  negative  save  for  small 
cervical  polyp.  Roentgen  findings :  Annular  filling-defect  with  marked 
narrowing  of  lumen  in  right  half  of  transverse  colon,  with  palpable 


Fig.  43.5.  Fig.  436. 

Figs.  433,  434,  435,  436. — Cancer  of  colon.     O,  obstruction.     F.  D.,  filling  defect. 

tumor  (Fig.  422).  No  roentgen  examination  of  stomach  requested. 
Findings  at  exploration:  Tumor  the  size  of  an  orange,  in  transverse 
colon,  involving  and  penetrating  posterior  wall  of  stomach.  Glands 
and  omentum  involved  and  adherent  to  abdominal  wall.  Tumor  in 
liver.     Lumen  of  bowel  permits  invagination  of  finger  past  tumor. 


REPORT    OF    CASES 


465 


Case  80,026,  male  aged  37  years.  Five  months  ago  he  suddenly 
developed  diarrhea  with  griping  pain.  The  stools,  which  were  four  or 
five  in  number  daily,  contained  mucus,  but  no  blood.  The  diarrhea 
ceased  after  two  months  and  was  followed  by  constipation  which  has 


Fig.  439.  Fig.  440. 

Figs.  437,  438,  439,  440.— Cancer  of  colon.     O,  obstruction.     F.  D.,  filling  defect. 
Photograph  of  specimen  in  corner  of  roentgenogram. 


continued  since.  He  is  obliged  to  take  cathartics  and  has  gone  for  a 
week  without  stooling.  When  the  bowel  does  not  move  he  has  general 
abdominal  soreness.  Normal  weight  165;  present  weight  135.  Defi- 
nite  thickening  felt   in   left   iliac   fossa.     Proctoscopic   examination 


30 


466  CANCER    OF    THE    COLON 

negative.  Cystoscopy  shows  edema  of  bladder-wall  and  bladder 
seems  dragged  upward.  Roentgen  findings:  Marked  obstruction  to 
enema  low  in  colon  (Fig.  423).  The  ingested  meal  shows  a  filling- 
defect  throughout  a  considerable  extent  of  the  descending  colon  and 
sigmoid  (Fig.  424).  Findings  at  exploration:  Tumor  of  sigmoid, 
probably  malignant.  The  growth  is  about  7  inches  long,  and  is  fixed 
to  the  bladder  and  to  the  pelvis  in  the  vicinitj^  of  the  left  ureter. 
Inoperable. 

REFERENCE 

1.  Hertz,  A.  F. :   "Constipation  and  Allied    Intestinal   Disorders." 
H.  Frowde,  London,  1909,  359. 


CHAPTER  XXIII 
DIVERTICULITIS 

According  to  McGrath/  Graser^  in  1899  was  the  first  to 
demonstrate  the  association  of  acquired  diverticula  with  '^iso- 
lated, circumscribed  adhesive  peritonitis"  on  the  colon,  the 
latter  condition  having  been  mentioned  by  Virchow  in  1853. 
Although  not  of  common  occurrence  as  compared  with  other 
lesions  of  the  large  bowel,  diverticulitis  is  met  with  sufficiently 
often  to  require  its  consideration  in  many  cases  with  symptoms 
referable  to  the  colon.  Thus  as  early  as  1907,  Mayo,  Wilson 
and  Giffin^  were  able  to  report  5  cases  operated  on  in  the  Mayo 
Clinic  and  in  1912  Giffin'^  collected  27  such  cases,  in  17  of  which 
there  was  involvement  of  the  sigmoid. 

McGrath,^  in  his  very  complete  review  of  the  pathology, 
has  brought  out  the  following  facts:  Nearly  all  these  diver- 
ticula are  of  the  ''false"  type,  that  is  to  say,  they  are  hernia  of 
the  mucosa  through  the  muscularis,  commonly  at  points  where 
the  latter  is  penetrated  by  vessels.  They  are  found  most  fre- 
quently in  the  sigmoid.  The  chief  causes  are  weakness  of  the 
muscularis  with  an  increase  of  intra-intestinal  pressure,  such  as 
occurs  in  stasis  and  gas  formation.  Diverticula  vary  in  size 
from  that  of  a  pea  to  a  hen's  egg.  They  are  usually  round  or 
ovoid,  and  most  often  sessile,  though  occasionally  pedunculated. 
The  opening  into  the  bowel  may  be  narrow  and  practically 
stenosed,  or  it  may  be  almost  as  wide  as  the  diverticular  cavity. 
The  sacs  usually  contain  fecal  matter  and  sometimes  fecaliths. 
Histologically,  the  sac-wall  is  made  up  of  mucosa,  submucosa 
and  serosa,  the  muscularis  being  slight  or  wanting.  The  mucosa 
may  be  slightly  atrophic  or  even  ulcerated,  but  the  most  con- 
stant pathologic  process  is  the  chronic,  proliferative  extramucosal 
inflammation,  the  "peridiverticulitis"  of  Wilson,  with  round-cell 
infiltration,  which  results  in  mass  formation. 

467 


468  DWERTICULITIS 

Prominent  features  of  the  symptomatology,  as  described  by 
Giffin,  are  the  following:  The  proportion  of  males  to  females 
appears  to  be  2  or  3  to  1.  An  incUnation  to  obesity  is  noted 
almost  without  exception;  the  patients  are  of  sound  flesh  with 
good  color,  and  where  loss  of  weight  occurs,  it  is  only  slight. 
Abdominal  pain,  usually  of  considerable  severity,  is  the  rule. 
Often  the  patient  is  able  to  localize  the  pain  to  the  sigmoid  or 
descending  colon.  Constipation  is  complained  of  by  the 
majority  and  is  often  of  more  than  moderate  severity.  Vesical 
symptoms,  such  as  urinary  frequency  and  tenesmus,  are  occa- 
sionally noted.  In  every  instance  of  diverticulitis  of  the  sig- 
moid, a  mass  was  felt  in  the  left  lower  quadrant  or  in  the  pelvis. 
The  proctoscopic  examination  is  likely  to  be  negative  unless  the 
tumor  has  intussuscepted  into  the  rectum.  Absence  of  blood 
from  the  stools  is  notable  and  this  is  explained  by  the  fact 
pointed  out  by  Wilson^  that  the  inflammatory  process  is  primarily 
extramucosal,  and  the  condition  is  really  a  peridiverticulitis. 

In  the  presence  of  these  symptoms  the  differential  diagnosis 
becomes  a  matter  of  importance.  One  condition  which  must  be 
eliminated  is  that  of  left-sided  appendicitis.  Here  the  roent- 
genologic examination  would  be  decisive  by  showing  the  posi- 
tion of  the  cecum.  The  most  difficult  differentiation  is  from 
carcinoma.  While  the  symptoms  are  not  typical  of  carcinoma, 
they  do  not  absolutely  exclude  it.  Indeed,  Wilson^  has  shown 
that  carcinoma  may  develop  from  diverticula. 

The  question  arises  as  to  what  can  be  expected  from  the 
x-ray.  In  1914,  Abbe^  reported  a  case  of  sigmoid  diverticulitis 
in  which  a  roentgenologic  examination  had  been  made  by  Le 
Wald.  A  bismuth  enema  showed  only  a  narrowing  of  the 
sigmoid.  Later  a  bismuth  meal  was  given  and  radiographs  taken 
up  to  the  tenth  day  showed  the  constant  presence  of  small  round 
spots  in  the  vicinity  of  the  sigmoid,  long  after  both  enema  and 
meal  had  been  evacuated.  The  shadows  admitted  of  but  one 
explanation,  namely,  bismuth  fluid  retained  in  the  diverticula. 
Our  experience  with  the  cases  hereinafter  described  indi- 
cates that,  in  some  instances  at  least,  the  roentgen  signs  of 


REPORT    OF    CASES 


469 


diverticulitis  are  more  or  less  characteristic, 
follows : 


The  cases  are  as 


Case  99,640,  male,  aged  55.  Examined  January  26,  1914.  Family 
and  personal  history  negative.  Gall-stones  (passed  one);  severe 
cholecystitis  and  peritonitis  fifteen  years  ago.  Twelve  years  ago  he 
was  operated  on  for  left  inguinal  hernia  and  hemorrhoids.  Clinical 
history:  Post-operative  abscess  followed  previous  operation  with 
Symptoms  of  cystitis.     The  abscess  developed  around  the  ligature  later, 


Fig.  441. — Case    99,640.      Roentgenogram    of  bariuni-filleci     colon    (enema),   showing 
marked  filling  defect  in  sigmoid  with  extralumenal  shadows  (diverticula)  D, 


which  was  passed  by  urethra.  Since  then  the  patient  has  had  symp- 
toms of  bowel  obstruction,  the  last  time  in  December,  1913,  one  attack 
five  years  prior  to  this.  There  were  left-sided  griping  and  gas  pains 
with  much  distention.  At  one  time  the  bowels  did  not  move  for 
eight  days;  ordinarily,  however,  they  moved  regularly.  Apparent 
lump  and  soreness  in  left  iliac  fossa  with  pressure  affecting  the  bladder. 
Pencil  stools  before  last  attack.  The  patient  returned  to  his  home, 
and  prior  to  his  operation,  March  17,  1914,  suffered  several  obstructive 


470 


DIVERTICULITIS 


attacks,  with  flatulence,  rumbling  and  stinging  pain  over  the  pubis  and 
left  side  during  bowel  movement.  Sensation  of  ''something  pushing 
up  from  rectum"  when  in  sitting  posture.     Some  weight  fluctuation 


Fig.  442. — Case  99,640.  Longitudinal  section  through  sigmoid,  showing  multiple 
diverticula  with  marked  thickening  of  intestinal  wall  and  narrowing  of  lumen.  A, 
mucosa;  B,  diverticula,  containing  fecaliths;  C,  canal  leading  to  diverticular  sac. 


A 

Fig.  443. — Cross  section  of  wall  of  normal  sigmoid,  photomicrograph,  magnified 
four  times,  showing  normal  mucosal  fold.  Note  that  this  fold  does  not  penetrate  the 
musculature.  A,  mucosa.  B,  mucosal  fold.  C,  [submucosa.  D,  musculature.  E, 
subperitoneal  fat.     F,  peritoneum. 


but  the  greatest  loss  at  any  one  time  was  12  pounds.  Urine  negative. 
Roentgen  examination:  January  27,  1914,  patient  was  examined  in  the 
routine  way  by  barium  enema.     Roentgenograms  showed  an  irregular 


REPORT    OF    CASES 


471 


filling-defect  with  marked  narrowing  in  the  sigmoid.  Small  barium 
shadows  were  observed  outside  the  lumen  of  the  bowel,  an  appearance 
quite  unusual,  and  at  that  time  inexplicable  (Fig.  441).     From  the 


Fig.  444. — Cross  section  of  wall  of  sigmoid,  photomicrograph,  magnified  four 
times.  Shows  mucosal  fold  and  submucosa  separating  the  circular  muscular  fibers 
and  penetrating  to  the  longitudinal  musculature.  An  early  diverticulum  of  this  type 
can  hardly  be  demonstrated  radiologically  because  of  the  absence  of  flask-like  dilata- 
tion. A,  mucosa.  B,  diverticulum.  C,  circular  muscle  fibers.  D,  subperitoneal  fat. 
E,  peritoneum. 


f"  £ 


Fig.  445. — Cross  section  of  wall  of  sigmoid,  photomicrograph,  magnified  four 
times.  Deep  seated,  late  stage  diverticulum  with  flask-like  ampulla.  The  diver- 
ticulum has  separated  the  circular  fibers  which  are  here  seen  compressing  the  neck, 
passed  through  the  longitudinal  bands  of  muscle  and  penetrated  into  the  subperitoneal 
fat.  This  advanced  type  offers  the  greatest  opportunity  of  radiologic  demonstration 
because  of  its  capacity  and  the  distance  from  the  intestinal  lumen.  A,  mucosa  of  bowel. 
B,  canal  leading  into  diverticular  cavity  at  C.  D,  musculature,  E,  subperitoneal  fat. 
F,  thickened  peritoneum. 


clinical  facts  and  the  roentgen  appearance,  W.  J.  Mayo  suggested  to 
the  patient  that  the  condition  might  be  diverticulitis.  Findings  at 
operation  (March   17,   1914) :  Diverticulitis  of  the  sigmoid.     Bowel 


472 


DIVERTICULITIS 


exceedingly  thick  and  adherent  to  pelvic  wall  posteriorly;  about  14 
inches  of  bowel  involved.  Operation:  Mikulicz.  Pathologist's  re- 
port: Tissue  removed,  sigmoid.     Diagnosis:  Diverticulitis  (Fig.  442). 

Case  105,595,  male,  aged  51.  Examined  May  7,  1914.  Family 
and  personal  history  negative.  Denies  any  previous  disease.  Appen- 
dectomy elsewhere,  without  any  exploration.  Clinical  history:  For 
ten  years  he  has  been  constipated.     In  the  past  two  years   he  has 


Fig.  446.— Case  105,595. 


Barium-filled  colon  (by  enema)  with  extra  lumenal  shadows 
(diverticula)  at  A. 


noticed  a  sore  lump  in  the  left  lower  abdomen  which  has  been  asso- 
ciated with  an  increase  of  constipation.  On  two  occasions  this  lump 
became  swollen  and  very  tender.  In  December,  1913,  he  had  a  chill 
with  fever,  and  griping  pain  with  gas,  marked  swelling  and  soreness  at 
the  spot  complained  of.  Recent  similar  attack  four  days  ago.  Stools 
small  and  tapered,  necessitating  laxatives,  but  no  blood  or  pus  noted. 
When  the  lump  is  swollen,  the  patient  urinates  frequently  with  some 
pain.  General  health  good.  Weight  loss,  5  pounds.  Phj^sical 
examination:  Tenderness  and  resistance  in  lower  left  abdomen. 
Rounded  elongated  mass  felt  by  bimanual  examination.  Rectum 
seems  negative  aside  from  small  hemorrhoids.     Proctoscopic  examina- 


REPORT    OF    CASES 


473 


tion :  Negative.  Roentgen  findings :  Negative  save  for  slight  enlarge- 
ment of  cecum.  At  the  same  time  small  shadows  were  noted  outside 
the  sigmoid  lumen,  but  their  significance  was  not  at  that  time  appre- 
ciated (Fig.  446).  Findings  at  operation:  Diverticulitis  of  sigmoid. 
Operation:  Mikulicz.  Pathologist's  report :  Tissue  removed,  sigmoid. 
Diagnosis:  Diverticulitis  (Fig.  447). 

Case  107,983,  male,  aged  49  years.  Examined  June  12,  1914. 
Previous  history  unimportant.  Catarrhal  jaundice  four  years  ago, 
with  epigastric  pain.  He  denies  lues  or  gonorrhea.  Clinical  history: 
Present  trouble  began  six  weeks  ago  with  gas  in  the  lower  bowel  and 


Fig.  447. — Case  105,595,  Cross  section  of  diverticulum,  photomicrograph,  magni- 
fied four  times.  A,  mucosa  of  sigmoid.  B,  neck  of  diverticulum  (not  well  shown  on 
account  of  depth  at  which  section  was  cut),  extending  from  lumen  of  sigmoid 
through  circular  muscular  fibers  to  diverticular  sac  at  C  D,  subperitoneal  tissue.  E, 
peritoneum. 

Note  that  mucosal  lining  of  the  diverticulum  is  like  that  of  the  sigmoid,  and  it  differs 
in  this  respect  from  the  inflammatory  pockets  produced  by  perforating  ulcer  of  the 
stomach  which  are  often,  but  wrongly,  spoken  of  as  diverticula. 


sharp,  shooting  pain  in  the  left  lower  abdomen,  passing  to  the  hypo- 
gastrium,  intermittent  in  character  and  relieved  spontaneously  or  by 
flatus.  Attacks  come  only  if  he  gets  a  ''cold,"  and  last  four  or  five 
days;  he  has  had  three  or  four  seizures  in  all.  During  the  intervals 
there  is  some  discomfort  from  gas,  which,  although  there  are  no  dis- 
tinct vesical  symptoms,  "interferes  somewhat  with  the  bladder." 
He  has  lost  some  weight  on  diet.  He  has  been  constipated  and  used 
laxatives  for  years.  He  has  had  occasional  tenderness  in  the  region 
complained  of  during  the  past  six  weeks.  Physical  examination: 
Mass  in  the  sigmoid  area,  not  now  tender.  Prostate  slightly  enlarged, 
otherwise  negative.  Small  hemorrhoids.  Roentgen  findings  (after 
opaque  enema) :  Filling-defect  in  upper  sigmoid.  Marked  spasticity 
of  transverse,  descending   colon   and   sigmoid  (Fig.  448).     A   reray 


474 


DIVERTICULITIS 


after  the  administration  of  belladonna,  was  suggested  but  could  not 
be  obtained.  This  request  was  made  because  of  the  great  amount  of 
spasm  noted,  which  had  to  be  considered  as  a  possible  cause  of  the  sig- 
moid deformity,  although  a  lesion  was  strongly  suspected.  In  the 
absence  of  a  reray  no  attempt  was  made  to  carry  the  diagnosis  further. 
Operation:  A  tumor  of  the  sigmoid  about  10  inches  in  length,  exten- 
sively adherent  to  the  lateral  wall  of  the  pelvis  in  the  vicinity  of  the 
common  iliac  vein  was  removed  (Mikulicz  operation).  Pathologist's 
report:  Diverticulitis. 


Fig.  448.- 


-Case    107,983.     Filling   defect  of   sigmoid   with   extralumenal   shadows — 
barium-filled  diverticula — at  A. 


Case  109,311,  man,  aged  54  years.  Operation  two  years  ago  else- 
where; gastro-enterostomy  for  duodenal  ulcer  and  excision  of  small 
growth  from  the  ileum,  microscopically  cancer.  He  was  completely 
relieved  until  two  weeks  ago  when,  following  indiscretion  in  diet,  he 
had  cramping  pain  in  the  left  iliac  fossa,  becoming  generalized  over  the 
abdomen.  The  pain  lasted  about  three  days,  and  the  patient  has 
gradually  grown  better,  though  his  appetite  is  poor,  and  there  is  some 
loss  of  weight  and  strength.  Constipation;  some  mucus  in  stools. 
During  the  past  two  days  he  has  had  burning  with  micturition  and 
nocturia  which  he  never  had  before.     Weight  loss,  10  pounds.     Oblong, 


REPORT    OF    CASES  475 

firm,  movable  mass  in  left  pelvis  felt  on  bimanual  examination.  Hem- 
oglobin 86.  Roentgen  findings:  Irregular  obstruction  of  sigmoid 
(Fig.  449).  Findings  at  operation:  Carcinoma  lower  sigmoid,  10 
inches  above  rectum,  involving  4  inches  of  sigmoid.  Obstructing 
tumor,  probably  developing  on  diverticula.  Adhesions  to  bladder  and 
left  ureter.  Operation:  Mikulicz.  Pathologist's  report:  (1)  Diver- 
ticulitis.    (2)  Carcinoma  on  diverticulitis. 


Fig.  449. — Case  109,.311.     Obstruction  at  O. 

Case  147,966,  man,  aged  .52  years.  One  year  ago  he  had  a  brief 
attack  of  shght  pain  and  soreness  in  left  iliac  fossa.  Three  weeks  ago 
he  had  cramps  in  the  lower  abdomen,  followed  by  a  little  fever  and  some 
soreness  in  the  left  iliac  fossa.  By  taking  Russian  oil  he  has  fairly 
soft  movements,  but  these  are  accompanied  by  pain  in  the  left  lower 
quadrant  and  some  cramping  in  the  rectum.  He  is  afraid  to  eat  solid 
food  because  of  the  increased  pain  when  heavy  fecal  matter  reached 
the  sore  area.  He  noticed  a  little  irritation  of  the  bladder  when  the 
present  attack  began.  Underweight  20  pounds.  Tenderness  and 
sense  of  mass  low  in  left  quadrant.  Roentgen  findings:  Diverticulitis 
of  sigmoid  (Fig.  450).  Findings  at  operation:  Tumor  of  the  sigmoid 
just  at  the  pelvic  brim,  about  4  inches  in  length,  closely  attached  to 
the  pelvic  wall,  with  an  abscess  in  the  mesentery  containing  thick  pus. 
Pathologist's  report:  Diverticulitis. 


476 


DIVERTICULITIS 


Fig.  450.— Case  147,966.     Involved  area  at  D. 


Fig.  451.— Case  143,262.     Obstruction  at  O. 


REPORT    OF    CASES  477 

Case  143,262,  man,  aged  35  years.  Two  years  ago  he  had  slight 
pain  in  the  left  abdomen  radiating  across  navel.  Recovery  in  two 
days.  Since  then  he  has  been  well  until  sixty  days  ago.  At  that  time 
he  was  abroad  and  suffered  a  severe  attack,  lasting  four  weeks.  The 
attack  was  accompanied  by  fever,  and  a  very  small  amount  of  blood 
was  noticed  in  the  stool  at  one  time.  His  physician  could  feel  a  tumor 
the  size  of  a  fist  in  the  left  lower  quadrant,  and  made  a  diagnosis  of 
diverticulitis  of  the  sigmoid.  This  seemed  to  be  confirmed  by  bis- 
muth plates  of  the  bowel.  Under  treatment  with  castor  oil  and  diet 
the  swelling  diminished  and  since  returning  to  this  country,  he  has 
felt  fairly  well,  save  for  some  ''weakness"  in  the  left  side.  His  bowels 
are  constipated.  Micturition  usually  normal,  but  there  was  some  pain 
with  urination  during  his  attack.  Weight  loss,  5  pounds.  Area  of 
resistance  in  left  lower  quadrant;  question  of  a  mass.  Roentgen  find- 
ings: Obstruction  of  the  sigmoid,  with  marked  spasticity  above  and 
below  the  point  of  obstruction  (Fig.  451).  Findings  at  operation: 
Tumor  of  the  sigmoid — diverticulitis?  carcinoma? — perforating  and 
adherent  to  parietal  peritoneum  at  brim  of  pelvis.  Tumor  mass 
about  5  inches  long,  loosened  with  difficulty.  Operation:  Mikulicz. 
Pathologist's  report:  No  diverticulitis  or  carcinoma  found.  (The 
specimens  examined  had  become  necrotic.  C.  H.  Mayo  considered 
the  case  one  of  diverticulitis.) 

The  outstanding  roentgenologic  feature  of  the  above  cases  is 
the  demonstration  in  some  of  them  of  oval  or  rounded  shadows 
projecting  from  or  lying  outside  the  intestinal  lumen,  and  repre- 
senting the  barium-filled  diverticula.  Such  shadows  in  con- 
junction with  narrowing  and  defective  filling  of  the  bowel  would 
seem  pathognomonic  of  diverticulitis.  While  a  carcinoma  might 
show  more  or  less  apparent  pocketing,  such  pockets  are  not 
likely  to  have  the  rounded  symmetry  of  diverticula.  In  the  in- 
stance of  carcinoma  supervening  upon  diverticulitis,  if  rounded 
extra-lumenal  shadows  were  present,  the  lesion  could  not  be  dis- 
tinguished from  a  benign  diverticulitis,  while  if  these  shadows 
were  not  present  the  case  would  probably  be  regarded  simply  as 
one  of  carcinoma. 

The  possibility  should  be  borne  in  mind  that  by  reason  of  a 
stenotic  inlet,  or  the  extremely  small  size  of  the  diverticula,  or 
because  they  contain  fecal  matter,  they  may  fail  to  fill  with  the 
clysma.     In  this  event  there  is  seen  only  a  filling  or  obstruction 


478 


DR'ERTICULITIS 


defect  proportioned  to  the  extent  of  inflamniatory  thickening  and 
not  distinguishable  roentgenologically  from  that  of  carcinoma. 
As  to  the  chance  of  a  fecaUth  being  seen,  that  would  depend  upon 
its  size.,  density  and  situation.  It  is  also  quite  possible  that 
sufficient  barium  may  enter  a  diverticulum  containing  a  f  ecaUth 
to  make  the  sac  visible. 

Diverticular  shadows  may  be  imitated  hj  phleboliths,  calci- 
fied glands,  renal  and  ureteral  calculi,  and  occasionally  by  barium 


Fig.  452. — At  operation  a  diverticulitis  was  found  in  the  sigmoid,  A  careful 
examination  of  the  transverse  colon  failed  to  discover  anj'  diverticula  in  this  part 
of  the  bowel.  The  extralumenal  shadows  at  B  are  probably  due  to  barium  in  con- 
tracted haustra. 


pent  up  in  contracted  haustra.  By  manipulation  during  the 
screen-examination  or  making  plates  at  different  angles  it  may 
be  possible  to  show  that  shadows  of  the  concretions  mentioned 
have  no  relation  to  the  bowel.  Plates  made  before  giving  the 
enema  or  meal  would  be  decisive. 

Haustral  shadows  sometimes  resemble  those  of  diverticula,  as 
shown  in  Fig.  452,  where  they  appear  to  be  detached  from  the 
lumen  of  the  bowel.     Some  differential  points  are : 


REPORT    OF    CASES 


479 


1.  Haustral  shadows  are  not  accompanied  by  a  filling-defect 
in  that  portion  of  the  bowel,  while  diverticular  shadows  may  be 
thus  accompanied. 

2.  Haustral  shadows  tend  to  disappear  or  change  their  situa- 
tion.    The  change  may  not  be  rapid  and  the  screen  examina- 


FiG.  456. 


Fig,  455. 
Figs.  453,  454,  455,  456. — Diverticulitis  of  pelvic  colon.     Involved  area  at  D. 

tion  should  be  sufficiently  prolonged  or  plates  should  be  made  at 
intervals  long  enough  to  permit  this  change  of  situation.  Diver- 
ticular shadows  maintain  a  fixed  position,  and  may  persist  after 


480  DIVERTICULITIS 

the  bowel  is  emptied  or  partially  emptied.  For  this  reason,  an 
examination  after  evacuation  of  the  colon  may  strengthen  the 
diagnosis. 

Although  Le  Wald's  case  indicates  otherwise,  the  liquid 
opaque  clysma  introduced  under  some  pressure,  after  purgation 
and  a  cleansing  enema,  is  probably  more  efficient  than  the  meal 
in  demonstrating  surgical  diverticulitis  and  is  more  convenient. 
Portions  of  the  meal  tend  to  scatter  in  small  masses  and  these 
may  be  confounded  with  diverticula.  However,  there  can  be 
no  objection  to  using  both  meal  and  enema. 

Since  the  shadows  of  diverticula  may  be  overlapped  by  the 
barium  in  the  bowel  at  certain  angles  of  view,  the  examination 
should  be  made  with  the  patient  in  various  positions.  Stereo- 
scopic ^plates  may  sometimes  give  additional  assistance. 

REFERENCES 

1.  McGrath,  B.  F. :    "Intestinal  Diverticula;    Their  Etiology  and 

Pathogenesis."     Surg.,  Gynec.  and  Ohstet.,  1912,  xv,  429-444. 

2.  Graser,  E.  :  "Das  falsche  Darmdivertikel."     Arch.f.  klin.  Chir., 

1889,  lix,  638-647.     Quoted  by  McGrath,  loc.  cit. 

3.  Mayo,   W.   J.,   Wilson,  L.   B.   and   Giffin,   H.   Z.:  "Acquired 

Diverticulitis  of  the  Large  Intestine."     Surg.,  Gynec.  and  Ohstet., 
1907,  V,  8-15. 

4.  GiFFiN,   H.   Z. :  "The  Diagnosis  of  Diverticulitis  of  the  Large 

Bowel;   a   Clinical   Review   of   Twenty-seven   Cases."     Jour. 
A.M.A.,  1912,  lix,  864-866. 

5.  Wilson,  L.B.:  "Diverticula  of  the  Lower  Bowel:  Their  Develop- 

ment and  Relationship  to  Carcinoma."     Annals  of  Surgery, 
1911,  liii,  223-231. 

6.  Abbe,  R. :  "A  Case  of  Sigmoid  Diverticulitis  Simulating  Malig- 

nancy; Demonstrated  by  Radiograph;  Operation  and  Speci- 
men."    Med.  Rec,  1914,  Ixxxvi,  190-191. 


CHAPTER  XXIV 
TUBERCULOSIS  OF  THE  COLON 

Though  much  less  common  than  cancer,  tuberculosis  of  the 
large  bowel  occurs  sufficiently  often  to  be  of  practical  interest. 
Pathologically,  the  tuberculous  lesions  may  be  either  of  the  ulcer- 
ative or  hyperplastic  type,  or  combinations  of  the  two.  Distal 
segments  of  the  bowel  are  seldom  invaded,  the  disease  nearly 
always  involving  the  proximal  portion,  especially  the  ileocecal 
valve,  cecum  and  appendix,  and  ascending  colon  (Brunner^). 
The  terminal  ileum  is  frequently  implicated.  The  condition  is 
usually  secondary  to  pulmonary  tuberculosis. 

Appended  are  the  histories  with  roentgenologic  findings  in 
four  cases  of  cecal  tuberculosis.  Filling-defects  or  obstruction, 
with  a  corresponding  palpable  mass,  constituted  the  chief 
findings.  These,  of  course,  are  identical  with  the  manifestations 
of  cancer,  so  that  strictly  roentgenologic  differentiation  is  impos- 
sible. However,  when  these  signs  are  localized  to  the  cecal 
region  the  examiner  should  at  least  be  chary  of  a  diagnosis  of 
cancer  without  investigating  the  clinical  history  and  examining 
the  lungs  by  the  x-ray. 

Case  149,397,  woman,  aged  52.  Ten  years  ago  she  had  a  surgical 
exploration  for  a  tumor  of  the  right  lower  abdomen.  She  was  told 
that  it  was  sarcoma ;  resection  was  not  done.  For  a  year  subsequently 
she  was  treated  with  the  x-ray.  About  six  months  after  the  explora- 
tion an  abscess  formed  in  the  region  of  the  scar  and  was  opened.  This 
has  recurred  once  or  twice  since.  She  thinks  the  tumor  has  increased 
slowly  in  size,  but  no  definite  increase  lately.  For  three  months  she 
has  had  diarrhea  with  one  to  four  stools  daily.  Some  irritation  of 
bladder  recently.  Weight  loss,  24  pounds  in  two  years.  Hemoglobin 
60.  Hard  irregular  mass  in  right  iliac  fossa.  Roentgen  findings: 
Enema  obstructed  in  upper  ascending  colon,  entire  cecal  region  unfilled 
(Fig.  457).  Findings  at  operation:  Hyperplastic  tuberculosis  of 
cecum,  forming  a  large  tumor  with  a  fistula,  involving  the  entire  cecum 
31  481 


482 


TUBERCULOSIS    OF    THE    COLON 


and  ascending  colon.  Ileum  involved  on  peritoneal  and  submucous 
coats  for  about  1  foot.  Glands  involved;  some  localized  peritonitis 
in  vicinity.  Right  Fallopian  tube  implicated.  The  growth  is  4  inches 
in  diameter  and  8  inches  long,  filled  with  scar  tissue.  Operation: 
Resection  of  the  right  Fallopian  tube,  12  inches  of  the  ileum,  appendix, 
cecum,  ascending  colon,  hepatic  flexure  and  part  of  the  abdominal 
wall  about  fistula.  Anastomosis  with  Murphy  button,  end  to  side. 
Pathologist's  report :  Tuberculosis  with  glandular  involvement. 

Case  161,981,  man,  aged  28.  Appendectomy  three  years  ago. 
Fourteen  months  later,  resection  of  portions  of  small  and  large  bowel 
for  "tumor  and  partial  obstruction."     Previous  to  the  first  operation 


Fig.     457.— Case  149,397.       Cecal  Fig.  458.— Case    161,981.     Cecal  tu- 

tuberculosis.     Obstruction  at  O.        berculosis.     Obstruction   and   filling    de- 
fect at  F.  D. 


he  had  three  attacks  of  severe  cramping  pain  in  the  right  lower  abdo- 
men with  nausea.  After  the  first  operation  he  had  similar  attacks  but 
less  severe.  After  the  second  operation  he  was  well  for  eleven  months, 
then  attacks  recurred  with  nausea  and  vomiting,  coming  at  first  at 
intervals  of  one  to  three  weeks,  now  almost  daily.  For  six  months  he 
has  noticed  a  mass  in  the  right  iliac  fossa.  Hacking  cough  for  two  or 
three  years;  rarely  raises  anything.  Weight  loss,  21  pounds  in  six 
months.  Hemoglobin  79.  Moderately  movable  mass  in  right  iliac 
fossa.  Roentgen  examination  of  chest  shows  diffuse  tuberculosis  of 
both  lungs.  Roentgen  findings:  Concentric  filling  defect  of  cecum, 
corresponding  to  an  obstructive  mass  (Fig.  458).  Findings  at  opera- 
tion: Large  tuberculous  tumor  of  the  cecum,  involving  about  1  foot  of 
the  terminal  ileum.     Many  tuberculous  areas  throughout  the  colon, 


REPORT    OF    CASES 


483 


chiefly  in  the  right  half.  Operation:  Resection  of  the  right  half  of 
the  colon.  Low  ileosigmoidostomy  by  suture.  Pathologist's  report: 
Tuberculosis. 

Case  111,425,  woman,  aged  32  years.  Shortening  of  round  liga- 
ments and  perineorrhaphy  six  weeks  ago,  elsewhere.  At  that  time  a 
growth  involving  the  cecum  was  found.  A  year  ago  she  had  an  attack 
of  constipation  and  cramps,  relieved  by  purgation  but  followed  by  low- 
grade  fever  for  two  weeks.  Since  then  the  constipation  has  been 
controlled  by  cascara  and  enemata.  Occasional  slight  colic;  some  pain 
in  the  right  upper  abdomen;  quite  sore  over  cecal  region.     Nothing 


Fig.  459.     Case   111,425.— Cecal   tuber- 
culosis.    Involved  area,  F.  D. 


Fig.  460.     Case  128,505. — Cecal  tuber- 
cxilosis.     Filling  defect,  F.  D. 


abnormal  in  stool;  no  urinary  symptoms.  Hemoglobin  85.  Tender- 
ness right  iliac  fossa.  Pulmonary  examination  shows  tubular  type 
of  breathing  and  delayed  expiration  both  apices.  Roentgen  findings: 
Filling-defect  of  cecum  with  marked  narrowing  and  irregularity  (Fig. 
459).  Findings  at  operation:  Tuberculosis  of  the  cecum,  involving 
terminal  ileum  and  ileocecal  valve.  Operation:  Resection  10  inches 
of  ileum,  cecum,  appendix  and  ascending  colon.  End  to  side  anasto- 
mosis by  suture. 

Case  128,505,  woman,  aged  24  years.  In  good  health  up  to  three 
months  ago  when  she  developed  soreness  and  tenderness  in  the  right 
lower  abdomen.  Later  her  physician  discovered  a  tumor  in  this 
region.     She  was  explored  elsewhere  one  month  ago,  and  tuberculosis 


484 


TUBEECULOSIS    OF    THE    COLON 


of  the  cecum  was  found.  Since  then  she  has  been  losing  weight;  she 
has  had  an  afternoon  rise  of  temperature  and  a  few  night  sweats.  The 
stools  have  been  loose  for  several  months  but  have  never  contained 
blood.     A  slight  cough,  but  no  expectoration.     Former  weight  124; 


Fig.  461. 


—    -.    FiLi.   402. 


Fig.  463. 
Figs.  461,  462,  463. — Tuberculosis  of  cecum.     F.  D.,  filling  defect.     O,  obstruction. 


present  92;  emaciated;  looks  anemic.  Hemoglobin  75.  Boggy 
tumor  mass  in  right  iliac  fossa;  not  tender.  Roentgen  findings: 
Filling-defect  of  cecum  and  ascending  colon  (Fig.  460).     Findings  at 


REFERENCE  485 

operation:  Hypertrophic  tuberculosis  of  cecum.  Mass  the  size  of  two 
fists.  Huge  glands  along  the  spine.  Terminal  ileum  involved.  Free 
fluid  in  abdominal  cavity.  Operation:  Ileocolostomy.  Attempt  at 
resection  not  advisable. 

REFERENCE 

1.  Brunner,  C:  "  Tuberculose,  Aktinomycose,  Syphilis  des  Magen- 
Darmkanals."     Stuttgart,  Enke,  1907,  49. 


CHAPTER  XXV 
CHRONIC  COLITIS 

In  his  monograph,  Schwarz^  describes  and  illustrates  the 
roentgenologic  findings  in  a  few  cases  each  of  chronic  catarrhal, 
mucous  and  ulcerative  colitis.  One  feature  common  to  all  three 
varieties  was  a  local  or  general  narrowing  of  the  colon,  which  was 
smooth  and  unhaustrated.  In  the  catarrhal  type,  the  contracted 
areas  changed  their  situation  rapidly.  Notwithstanding  the 
narrowing,  the  enema  filled  the  colon  very  quickly.  Besides 
the  wandering  diffuse  contractions,  exaggerated  peristalsis  and 
antiperistalsis  were  noted,  indicative  of  a  hyperirritability.  In 
the  mucous  type,  with  the  opaque  meal,  the  shadow  of  the  colon 
was  persistently  narrow  and  had  a  very  peculiar  flecked  and 
marbled  appearance,  due  probably  to  the  bismuth-holding  clumps 
of  mucus.  The  ulcerative  type  showed  a  narrow,  stippled  colon- 
shadow  with  delicate  arborizations. 

The  cases  of  mucous  colitis  and  catarrhal  colitis  which  we 
have  examined  with  the  ingested  meal  or  enema  either  gave 
negative  findings,  or  at  most  showed  only  a  vacillating  spasticity 
of  the  bowel  which  had  little  diagnostic  import.  Permanently 
contracted  and  unhaustrated  areas  were  not  noted  in  any 
instance.  We  have  not  seen  barium-holding  clumps  or  barium- 
ized  mucous  casts  which  might  be  considered  pathognomonic 
of  mucous  colitis.  This  may  have  been  due  to  the  fact  that 
they  are  not  constant  findings  or  that  our  cases  were  too  recent. 
On  the  other  hand,  our  cases  of  colitis  of  the  granulating  or 
ulcerating  type  have  given  consistently  positive  roentgen  find- 
ings. Examination  was  by  clysma  usually.  The  most  strik- 
ing roentgen  characteristics  noted  were  permanent  narrowing 
and  lack  of  haustration  in  the  involved  areas  of  the  colon.  These 
findings  were  logically  accounted  for  by  the  organic  changes 

486 


REPORT    OF    CASES 


487 


found  at  operation  and  at  necropsy,  notably  the  pronounced 
infiltration  and  thickening  of  the  intestinal  wall.  This  also 
explains  the  fact  that  the  roentgen  appearance  was  not  altered 
by  giving  belladonna  in  full  doses,  as  was  tried  in  a  few  cases. 
Incompetence  of  the  ileocecal  valve,  mentioned  by  Schwarz  as 
a  feature  of  his  cases,  was  noted  in  every  instance.  Following 
are  some  case  histories: 

Case  125,312,  man,  aged  24  years.     Persistent  diarrhea  for  twelve 
years.     Ordinarily  he  has  about  five  bowel  movements  daily,   but 


Fig.  4G4.— Case  125,312.     Chronic  colitis. 

there  are  periods  off  and  on,  lasting  several  days,  when  he  has  eighteen 
or  twenty  stools  daily.  At  these  times  the  stool  is  very  thin  and  bloody 
and  contains  mucus.  No  relief  has  been  obtained  from  treatment 
with  various  drugs,  including  emetine.  No  loss  of  weight.  Sugges- 
tion of  a  movable  rounded  mass  at  cecum.  Proctoscopic  examination: 
Marked  granular  colitis;  bowel  thick,  very  tender  and  bleeds  easily; 
no  ulceration  found.  Stool  report:  No  parasites  found.  Roentgen 
findings :  Smooth,  narrow  colon,  devoid  of  haustra  (Fig.  464) .  Findings 
at  operation:  Much  congestion  of  walls  of  colon.  Prolapsed  cecum. 
Appendix  adherent  to  ascending  colon.     Operation:  Appendicostomy, 


488 


CHRONIC    COLITIS 


Case  146,817,  man,  aged  38  years.  For  two  years  he  has  had 
attacks  of  diarrhea  lasting  from  two  weeks  to  three  months.  The 
stools  range  in  number  from  five  to  twent}^  daih\  They  are  of  rice- 
water  character,  odorless  or  not  offensive,  with  mucus  and  blood. 
During  the  past  three  months  there  has  been  much  bright  red  blood 
in  the  stools.  Occasionally  he  has  cramps  and  tenesmus  before  the 
bowels  move.  Weight  fluctuant;  present  loss,  26  pounds.  Hemo- 
globin 70.  Wassermann  negative.  Slight  gurgling  over  cecum. 
Little  tympanitis.  No  rigidity.  Proctoscopic  examination:  No  evi- 
dence of  ulceration.     Stool  report:  No  parasites,  tubercle  bacilli,  red 


Fig.  465.— Case  146,817.     Chronic  colitis. 

blood  corpuscles  or  pus  cells.  Roentgen  findings:  Colon  markedly 
contracted  and  unhaustrated  throughout,  indicating  a  chronic  inflam- 
matory process  (Fig.  465).  Clinical  diagnosis:  Chronic  colitis.  Find- 
ings at  operation:  Colon  contracted  to  about  the  caliber  of  the  small 
intestine.  Wall  moderately  thickened,  vessels  injected  and  the^bowel 
of  deep  reddish  color.  General  appearance  of  a  plastic  peritonitis. 
Condition  seemed  to  be  present  from  cecum  to  rectum,  gradually  in- 
creasing from  cecum  down.  Sub-acute  appendix.  Operation :  Brown 
operation  (ileostomy).  Cecum  brought  up  through  separate  incision 
for  J  colostomy  later  if  advisable.     Appendectomy'  secondary. 

Case  107,128,  man,  aged  54  years.     Diarrhea  for  eleven  years. 
Daily  average  of  six  stools,  chiefly  about  breakfast  time.     He  has 


REPORT    OF    CASES 


489 


often  noted  streaks  of  bright  blood  in  the  stool.  Some  soreness  in  the 
lower  abdomen,  but  never  any  distinct  pain.  Only  slight  loss  of 
weight.  Physical  examination :  Hemorrhoids.  Mucous  membrane  of 
rectum  feels  granular  and  edematous.  Hemoglobin  30.  Wassermann 
negative.  Roentgenogram  of  chest  shows  healed  tuberculosis  of  right 
upper  lobe.  Proctoscopic  examination:  Dijffuse  granular  colitis; 
bowel  gradually  narrowed  to  the  diameter  of  a  twenty-five-cent  piece. 
Stool  report:  Loose  brown  stool  with  mucus,  red  blood  corpuscles  and 
pus;  no  tubercle  bacilli  or  parasites.     Roentgen  findings:  Narrow, 


Fig.  466. — Case  107,128.     Chronic  colitis.     Sausage-like  colon. 
No  haustration. 


smooth,    sausage-like    colon.     Hepatic    and    splenic    flexures    ptosed 
(Fig.  466).     Clinical  diagnosis:  Chronic  colitis.     No  operation. 

Case  126,013,  woman,  aged  25  years.  About  eight  years  ago  each 
autumn  for  two  or  three  years,  she  had  attacks  of  hemorrhage  from 
the  bowel.  The  hemorrhage  occurred  with  nearly  every  defecation 
and  continued  for  two  weeks  to  two  months.  With  the  attacks  there 
was  some  pain  in  both  lower  abdominal  quadrants.  Five  years  ago 
she  passed  a  concavo-convex  mass  of  material  about  3  inches  long 
which  seemed  to  be  made  up  of  hair.  Following  this  no  hemorrhage 
occurred  until  six  months  ago,  and  again  six  weeks  ago.  Physical 
examination  shows  tenderness  in  left  lower  quadrant.     No  hemor- 


490 


CHEONIC    COLITIS 


Fig.  467.— Case  126,013.     Chronic  colitis. 


Fig.  468.— Case  121,271.     Chronic  colitis. 


REPORT    OF    CASES 


491 


rhoicls.  Roentgen  examination  of  chest  shows  healed  tuberculosis  of 
right  apex,  and  thickened  pleura  forming  pocket  over  periphery  of 
left  lung.     Proctoscopic  examination:  Generalized,  chronic  inflamma- 


FiG.  468a. 


Fig.  4686. 


Fig.  468c. 


tory  condition  of  bowel  as  far  as  could  be  seen;  bleeds  easily.  Stool 

report:    Negative    for    tubercle    bacilli;    no    parasites    found;  blood 

present.     Roentgen   findings:    Smooth,   narrow,  unhaustrated  colon, 
suggestive  of  chronic  colitis  (Fig.  467).     Xo  operation. 


492 


CHRONIC    COLITIS 


Case  121,271,  man,  aged  48.  Good  health  up  to  twenty-two  years 
ago,  then  onset  of  diarrhea  for  six  months,  with  two  or  three  stools 
daily;  no  pus  or  blood.  Well  for  a  j^ear,  then  recurrence  of  the  diar- 
rhea. For  the  past  year  he  has  had  a  daily  diarrhea — about  foui 
watery,  slimy  stools.  Slight  mid-abdominal  gas  pains  after  move- 
ments. Underweight  80  pounds  for  the  past  five  years.  Hemoglobin 
80.  Total  gastric  acidity  12;  all  combined.  Proctoscopic  examina- 
tion: Diffuse  superficial  ulceration  of  bowel,  not  typical  of  any  especial 
lesion.  Stool  report:  Loose  brown  stool,  chiefly  mucus;  red  blood  and 
pus  cells;  cercomonades.  No  amebse.  Roentgen  findings:  Colon 
narrow  and  more  or  less  smooth  throughout  (Fig.  468).  Clinical 
diagnosis:  Chronic  colitis.     No  operation. 


Fig.  468d. 

Roentgenograms  of  other  cases  of  chronic  ulcerative  or 
granular  colitis,  confirmed  at  operation  or  necropsy,  are  shown 
in  figures  468a,  4686  and  468c.  Figure  468c  was  a  case  of 
chronic  granular  colitis;  the  peculiar  appearance  of  the  de- 
scending colon  is  due  to  a  partial  involuntary  evacuation  of 
the  enema  before  the  roentgenogram  was  made;  figure  468d 
is  a  photograph^of  a  portion  of  the  bow^el  at  autopsy. 


REFERENCE 

1.  ScHWARZ,  G.:  "Klinische  Roentgendiagnostik  des  Dickdarms 
und  ihre  Physiologischen  Grundlagen."  Berlin,  Springer,  1914, 
100-10. 


CHAPTER  XXVI 
CHRONIC  INTESTINAL  STASIS  AND  CONSTIPATION 

Delayed  progress  of  food  material  through  the  alimentary- 
tract  has  been  given  renewed  interest  by  the  work  of  W.  Arbuth- 
not  Lane.^  Prior  to  his  investigations,  retarded  passage  of  the 
fecal  current  and  the  symptoms  arising  therefrom  had  been 
broadly  covered  by  the  term  "constipation,"  and  considered 
chiefly  as  a  functional  disorder  affecting  particularly  the  lower 
bowel.  But,  by  extending  the  field  to  include  delayed  transit 
through  any  part  of  the  intestinal  tract,  from  any  cause,  ad- 
vancing novel  veiws  as  to  etiologic  relationships  and  surgical 
treatment,  and  inventing  the  term  "intestinal  stasis,"  Lane  has 
created  an  apparently  new  and  important  domain.  From  his 
work  and  that  of  his  followers  and  opponents  an  extensive 
literature  has  arisen.  Notwithstanding  this,  the  matter  has 
not  as  yet,  crystallized  into  a  definite  and  accepted  entity 
susceptible  of  ready  and  clear  understanding. 

Einhorn^  contends  that  "visceroptosis  giving  rise  to  intestinal 
angulations  (designated  as  kinks  by  Lane)  and  the  formation  of 
partial  stenoses  with  delayed  prochoresis,"  originated  with  F. 
Glenard.  Einhorn  states  further  that  the  theory  of  intestinal 
stasis  leading  to  the  absorption  of  poisons  within  the  intestine,  or 
auto-intoxication,  was  advanced  long  ago  by  Bouchard,  Combe 
and  others.  However,  Lane  has  at  least  developed  these 
theories  to  greater  lengths  and  logically  carried  them  to  courage- 
ous surgery. 

Lane  has  defined  stasis  as  "such  a  delay  of  the  contents  of  the 
intestines  in  some  portion  of  the  gastro-intestinal  tract,  but  more 
particularly  in  the  large  bowel,  as  allows  the  absorption  into  the 
circulation  of  a  large  quantity  of  toxic  material  than  can  be  dealt 
with  effectually."  "This  delay,"  he  states,  "results  from  a 
mechanical  alteration  in  the  normal  arrangement  of  the  drainage 

493 


494  CHRONIC    INTESTINAL    STASIS    AND    CONSTIPATION 

apparatus.  In  early  life  it  is  produced  by  an  abnormal  disten- 
tion of  the  intestine,  consequent  on  too  frequent  feeding,  or  by 
the  use  of  articles  of  diet  of  an  unsuitable  nature.  Later,  it  is 
brought  about  and  accentuated  by  the  erect  posture  of  the  trunk 
which  is  assumed  from  the  time  of  getting  up  until  going  to  bed." 
He  holds  that  the  dragging  strain  of  the  intestine  upon  its  princi- 
pal points  of  support  tends  to  the  production  of  bands  and  kinks 
at  these  points.  The  bands,  he  states,  are  not  inflammatory 
but  evolutionary,  that  is  to  say,  they  represent  a  compensatory 
effort  of  nature.  The  points  at  which  these  bands  and  resulting 
kinks  occur  more  commonly,  he  claims,  are: 

1.  The  pylorus. 

2.  The  terminal  coil  of  ileum. 

3.  The  outer  aspect  of  the  cecum  and  ascending  colon. 

4.  The  hepatic  flexure. 

5.  The  splenic  flexure. 

6.  The  sigmoid  loop. 

Symptoms  of  the  auto-intoxication  consequent  upon  stasis 
include:  Loss  of  fat,  impaired  circulation  of  the  blood,  partial 
inhibition  of  respiration  which  is  often  entirely  diaphragmatic, 
staining  of  the  skin,  offensive  perspiration,  pain  and  weakness  in 
the  skeletal  muscles,  morning  headaches,  and  increased  sus- 
ceptibility to  infections  of  the  gums,  tubercle,  rheumatoid  arthri- 
tis, gout,  etc.  Lane  claims,  further,  that  as  a  result  of  enlarge- 
ment and  abrasion  at  the  point  of  stress  local  ulcers  and  cancers 
occur,  and  numerous  remote  lesions  are  set  up  by  the  systemic 
toxemia  and  irritation.  This  inclusive  feature  of  Lane's  con- 
ception of  stasis  makes  the  subject  momentous.  If  it  can  be 
established  that  ulcers  and  cancers  of  the  digestive  tract,  goiter, 
mammary  cancer,  tuberculosis,  etc.,  are  sequelae  of  intestinal 
stasis,  then  the  diagnosis  and  treatment  of  the  antecedent 
condition  are  of  vast  import. 

Lane's  theory  of  stasis  has  been  vigorously  combated  by 
Einhorn,  Bassler,^  Hertz^  and  many  others.  Einhorn  objects  to 
calling  the  digestive  canal  a  "drainage-tube,"  and  comparing 
it  to  a  sewer  system,  in  which  any  clogging  must  cause  disaster. 


CHRONIC    INTESTINAL    STASIS    AND    CONSTIPATION  495 

He  considers  intestinal  stasis  only  another  name  for  constipa- 
tion, and  holds  that  constipation  does  not  cause  auto-intoxica- 
tion. He  believes  that  if  we  did  not  need  the  colon  we  would  not 
have  it;  or  it  would  show  decided  signs  of  degeneration,  which  it 
does  not,  hence  ileocolostomy  or  colectomy  is  not  justifiable  for 
functional  disturbances.  Bassler  states  that  he  has  had  167 
cases  which  had  Lane  kinks,  but  only  5  of  these  showed  delayed 
prochoresis.  He  thinks  that  Lane  bands  are  probably  physio- 
logic, that  sagging  of  the  transverse  colon  does  not  necessarily 
mean  stasis,  and  that  operation  should  be  reserved  for  intestinal 
obstruction,  pure  and  simple.  DanieP  disagrees  with  Lane  as  to 
the  origin  of  bands  and  kinks,  and  holds  that  they  are  due  to 
local  peritonitis  resulting  from  bacterial  activity.  Hertz  be- 
lieves that  ileal  stasis  is  a  normal  phenomenon  resulting  from 
the  action  of  the  ileocecal  sphincter;  although  it  may  be  increased 
by  spasm  of  the  sphincter  as  a  result  of  disease  in  the  neighbor- 
hood of  the  cecum.  He  states,  further,  that  ptosis  of  the  intes- 
tines does  not  lead  to  stasis,  except  in  rare  instances  at  the  splenic 
flexure,  a  pelvic  cecum  or  transverse  colon  being  compatible  with 
perfect  health  and  normal  intestinal  action.  He  is  of  the  opinion 
that  in  most  cases  of  constipation  a  single  part  of  the  bowel  is 
involved;  and  that  even  in  the  cases  in  which  the  entire  colon  is 
involved  medical  treatment  almost  invariably  succeeds. 

Keith, "^  who  does  not  accept  Lane's  theory  of  stasis,  and 
denies  that  kinks  produce  delay  of  the  food  stream,  thinks  that 
he  has  found  a  possible  explanation  in  his  own  observations.  He 
has  noted  in  the  myenteric  plexus  (Auerbach's),  or,  rather, 
intermediate  between  it  and  the  muscle-fibers,  neuromuscular 
cells,  partaking  of  the  characters  of  both  nerve  and  muscle, 
which  he  calls  "nodal  tissue"  because  of  its  similarity  to  nodal 
tissue  in  the  heart.  He  finds  that  this  tissue  is  plentiful  in  the 
neighborhood  of  the  sphincters  of  the  digestive  tube,  as  well  as  at 
certain  other  points,  and  suggests  that,  like  the  nodes  in  the  heart, 
each  local  aggregation  of  nodal  tissue  serves  as  a  pacemaker  for 
rhythmical  contraction  (peristalsis)  in  the  zone  distal  to  it.  He 
does  not  think  it  over-presumptuous  to  suppose  that  irregulari- 


496  CHEONIC    INTESTINAL    STASIS    AND    CONSTIPATION 

ties  of  impulse-conduction  may  occur  in  these  nodal  systems  and 
cause  stasis  in  the  same  way  that  ''heart-block"  is  produced. 
The  effect  of  disordered  conduction,  he  believes,  is  not  hmited  to 
the  related  sphincter,  but  extends  to  the  bowel  segment  beyond, 
and  that  disturbance  of  rhythm  in  any  one  zone  tends  to  upset 
the  rhythm  in  other  zones.  While  Keith's  theory  does  not  carry 
us  far  toward  the  final  solution  of  stasis,  it  offers  a  plausible  ex- 
planation of  the  manner  of  its  production,  and  again  brings  into 
the  foreground  the  musculature  of  the  alimentary  tract. 

Moynihan''  seems  to  speak  wisely  when  he  says:  ''I  do  not 
hesitate  to  say  that  the  whole  question  of  stasis  is  one  which  will 
have  to  be  considered  by  all  of  us  and  be  put  to  the  proof. 
It  cannot  be  dismissed  with  a  shrug  or  a  sneer,  for  there  is  truth 
in  the  matter.  Among  much  that  is  dross  there  lies  a  nugget 
of  pure  gold." 

It  is  quite  obvious  that  the  roentgen-ray  offers  a  convenient 
means  for  demonstrating  the  evidences  of  stasis.  Accordingly, 
Jordan^  who  early  took  up  the  work  for  Lane,  has\called  attention 
to  the  following  roentgenologic  signs: 

1.  Dilatation  and  writhing  peristalsis  of  the  duodenum.  He 
lays  much  emphasis  upon  duodenal  distention,  claiming  that 
when  this  is  present,  other  evidences  of  stasis  will  also  be  found, 
and  that,  conversely,  in  the  absence  of  duodenal  dilatation  stasis 
is  not  likely  to  exist. 

2.  Ileal  stasis,  with  delay  of  the  intestinal  contents  in  the 
terminal  ileal  coils.  In  some  instances  this  may  be  due  to  drop- 
ping of  the  lower  coil  so  that  the  terminal  segment  has  a  steep 
ascent  to  the  ileum.  In  others  there  is  obstruction  by  an  adher- 
ent appendix,  or  by  a  kink. 

3.  Kinks.  The  points  where  Jordan  finds  kinks  most  com- 
monly are  at  the  duodeno-jejunal  juncture  (hence  the  duodenal 
dilatation  above  mentioned),  the  terminal  loop  of  the  ileum 
(particularly  about  4  inches  from  its  terminus),  the  hepatic 
flexure,  the  splenic  flexure,  and  the  sigmoid.  These  kinks  are 
evidenced  by  localized  narrowing,  fixation  (as  shown  by  lessened 
movement  on  palpation,  forced  respiration  and  change  of  pos- 


CHRONIC    INTESTINAL    STASIS    AND    CONSTIPATION  497 

ture)  tenderness,  dilatation  proximal  to  the  stenosis  and  delay  of 
the  intestinal  content. 

4,  New  formed  bands  about  the  appendix,  kinking  and 
fixing  it. 

5.  Elongation,  dilatation  and  looping  of  the  rectum. 

These  findings  have  formed  the  groundwork  of  the  roentgen- 
ology of  stasis.  To  a  varying  extent  and  with  additions  they 
have  been  adopted  by  many  other  observers.  Thus  Pfahler^ 
has  noted  kinks,  spasms,  twists,  and  adhesions  in  A^arious  parts 
of  the  bowel.  He  has  observed  obstruction  at  the  splenic  flexure 
by  a  gas-distended  splenic  loop.  Case^°  sees  kinks  less  frequently, 
but  often  finds  the  distal  colon  to  be  spastic.  He  dwells  upon 
incompetence  of  the  ileocecal  valve  as  a  factor  in  stasis. 

Brown ^^  reemphasizes  the  relation  of  the  enteroptic  habitus 
to  visceral  ptosis  and  hence  to  stasis.  Cole^^  says  that  the  whole 
subject  of  stasis  centers  around  the  roentgenologic  findings; 
therefore,  it  is  essential  that  the  roentgenologic  foundation  be 
sound,  soUd  and  scientific.  He  vigorously  condemns  the  use  of 
roentgenograms  as  a  weapon  with  which  to  urge  surgical  proced- 
ure for  some  preconceived  diagnosis. 

The  validity  of  the  signs  of  stasis  exploited  by  Jordan  and  his 
followers  is  not  accepted  by  all  roentgenologists.  Hertz^^  asserts 
that  intestinal  stasis  does  not  lead  to  duodenal  kinking,  dilata- 
tion or  ulceration,  and  points  to  the  fact  that  duodenal  ulcers  are 
associated  with  an  unusually  rapid  passage  of  chyme  out  of  the 
stomach  and  through  the  whole  of  the  small  intestine.  He  also 
says  that  when  the  stomach  empties  rapidly,  the  duodenum  con- 
tains more  barium  at  a  given  moment.  Hence  it  appears  dilated, 
the  normal  peristalsis  and  segmentation  are  rendered  more 
clearly  visible,  and  this  accounts  for  so-called  ''^Tithing." 
Segmentation  in  the  terminal  ileum  is  very  active  and  this,  he 
thinks,  may  be  mistaken  in  the  roentgenogram  for  organic  nar- 
rowing. As  to  incompetency  of  the  ileocecal  valve  he  feels  that 
the  valve  does  not  normally  prevent  regurgitation  into  the  ileum, 
as  he  has  seen  this  with  a  pressure  as  low  as  1  foot  of  water. 
Regurgitation  is  not  due  to  antiperistalsis,  he  claims,  as  a^-ray 

32 


498  CHRONIC    INTESTINAL    STASIS    AND    CONSTIPATION 

investigations  have  shown  that  antiperistalsis  does  not  occur  in 
man  under  normal  conditions. 

Regarding  stasis,  Mixter^^  says:  ''Since  the  advent  of  the 
roentgen-ray  much  has  been  learned  and  many  mistakes  have 
been  made.  It  is  safe  to  say  that  the  old  ideas  of  the  positions 
of  the  abdominal  viscera  have  undergone  a  great  change  in  the 
last  few  years.  Their  positions  and  shapes  are  becoming  better 
known,  and  w^hat  a  short  time  ago  were  considered  malpositions 
or  malformations  are  now  known  to  be  but  slight  variations  from 
the  normal,  if  there  is  any  such  thing  as  a  normal  arrangement. 
The  large  intestine  is  a  marked  example  of  this  rule ;  it  never  lies 
in  the  regular  hnes  and  curves  as  shown  in  the  diagrams  of  the 
old  anatomists.  There  are  innumerable  variations,  due  to  con- 
genital or  acquired  folds  of  the  peritoneum,  and  many  have  too 
quickly  decided  that  anything  unusual  must  be  a  serious  physical 
defect,  and  the  cause  of  certain  trains  of  symptoms.  *  *  *  Fecal 
stasis  is  recognized  as  an  evil,  and  many  operations  have  been  de- 
signed and  performed  for  its  relief  that  are  useless  or  do  positive 
harm.  *  *  *  Ptosis  does  not,  or  should  not,  always  mean 
operation.  The  interrelation  of  fecal  stasis  and  the  neuroses  and 
auto-intoxications  of  all  kinds  are  subjects  that  require  further 
investigation  and  study,  though  day  by  day  and  year  by  year 
our  knowledge  is  steadily  advancing.  The  medical  clinician,  the 
neurologist,  the  psychologist,  the  bacteriologist  must  each  do 
his  part,  and  they  should  be  aided,  not  over-shadowed,  by 
the  roentgenologist,  whose  mechanical  findings  may  so  often  be 
misinterpreted." 

Speaking  as  a  surgeon,  Coffey ^^  offers  this  warning:  "Roent- 
gen observation  is  of  inestimable  value  in  the  study  of  these  cases, 
but  is,  I  concede,  the  most  dangerous  agent  yet  placed  at  the 
disposal  of  the  unscrupulous  surgeon,  because  it  is  so  convinc- 
ing to  the  laity,  and  at  the  same  time  so  meaningless  when  con- 
sidered independently  of  the  history  of  the  case  and  not  properly 
interpreted." 

Hertz^^  does  not  seek  to  minimize  the  importance  of  intestinal 
hypomotility.     On  the  contrary,  in  his  book,  he  has  admirably 


CHRONIC    INTESTINAL    STASIS    AND    CONSTIPATION  499 

presented  the  whole  subject  of  constipation  from  every  view- 
point, including  the  roentgenologic.  A  summary  of  his  observa- 
tions may  serve  to  correct  the  spreading  assumption  that  consti- 
pation is  a  purely  mechanical  matter.  Admitting  wide  varia- 
tions within  the  normal,  he  says:  "For  practical  purposes  an 
individual  may  be  considered  constipated  if  his  bowels  are  not 
opened  at  least  once  in  every  forty-eight  hours.  *  *  *  Constipa- 
tion may  be  defined  as  a  condition  in  which  none  of  the  residue  of 
a  meal  taken  eight  hours  after  defecation,  is  excreted  within 
forty  hours."  He  divides  constipated  persons  into  two  great 
classes:  First,  those  in  whom  passage  through  the  intestine  is 
delayed,  but  defecation  is  normal.  Second,  those  in  whom  there 
is  no  delay  in  arrival  of  fecal  material  at  the  pelvic  colon,  but 
final  excretion  is  not  adequately  performed.  In  the  first  class 
delayed  prochoresis  may  be  due  to : 

A.  Deficient  motor  activity  of  the  intestines. 

B.  Excessive  force  required  to  carry  the  feces  to  the  pelvic 
colon. 

The  A  group  may  have  as  causes:  (1)  Weakness  of  the  in- 
testinal musculature,  which  may  be  constitutional  or  senile,  or  the 
result  of  chlorosis,  cachexia,  rickets,  fevers,  over-distention  by 
gas,  obesity  (fatty  degeneration  of  muscle) .  (2)  Deficient  reflex 
activity  of  the  intestine  from  insufficient  food;  insufficient 
chemical  and  mechanical  excitants  of  intestinal  activity,  ex- 
cesive  digestion  and  absorption  of  food  (greedy  colon)  or 
deficient  exercise.  Reflex  activity  may  be  impaired  also  by 
catarrhal  conditions  of  the  mucosa,  long-continued  irritation 
by  purgatives,  astringents  (tannin  in  tea  and  coffee)  or  by  de- 
pression of  the  nervous  system  (neurasthenia,  hypochondriasis). 
(3)  Inhibition  of  motor  activity  by  lead  poisoning,  depressing 
emotions,  or  painful  abdominal  viscera  (ovaritis,  cholecystitis, 
appendicitis) .  (4)  Spasticity  of  the  intestinal  musculature  (pa- 
tients usually  neurotic,  often  brain-workers).  A  localized 
spasticity  of  some  part  of  the  colon  is  often  accompanied  by 
spasm  of  the  sphincters. 

The  B  group  may  result  from  obstruction  by  an  excess  of 


500  CHRONIC    INTESTINAL    STASIS    AND    CONSTIPATION 

feces,  or  dry  hard  feces  (insufficient  supply  of  water,  excessive 
loss  of  water  by  other  channels,  excessive  absorption  of  water), 
deficient  fat  in  the  diet,  obstruction  by  organic  stricture  fnearly 
always  malignant),  kinking  of  the  intestine  (of  which  he  has 
noted  but  one  instance),  pressure  on  the  intestine  by  tumors 
without,  and  chronic  intussusception. 

For  the  second  of  the  two  great  classes  of  constipation  he  pro- 
poses the  name  ''  dyschezia. "  The  passage  of  feces  to  the  distal 
colon  may  be  normal  or  even  unusually  rapid,  but  the  act  of  defe- 
cation does  not  empty  the  lower  bowel  as  completely  as  it 
should.  The  causes  include  habitual  disregard  of  the  call  to 
stool,  weakness  of  the  abdominal  and  pelvic  muscles,  weakness  of 
the  defecation  reflex  (tabes),  h^^steria,  hard  and  bulky  feces, 
functional  and  organic  strictures  of  the  anal  canal  and  sphincter, 
and  pressure  on  the  rectum  by  a  pelvic  tumor  or  retroverted 
uterus. 

Schwarz^^  distinguishes  two  types  of  chi'onic  obstipation,  the 
hypokinetic  and  dyskinetic.  In  the  hypokinetic  type  the  slow 
transport  of  the  ingested  meal  is  associated  with  a  lessening  of 
peristaltic  action  in  the  distal  half  of  the  colon,  continuity  of  the 
fecal  mass,  belated  gradual  ejection  into  the  end-gut,  and  frag- 
mentary emptying.  Elongation  of  the  colon  is  a  frequent  addi- 
tion to  this  syndrome.  In  the  dyskinetic  type  there  is  a  hy- 
perfunction  of  the  transverse  and  descending  colons,  the  fecal 
mass  is  broken  up  and  separated,  and  the  abnormal  contraction 
of  the  mid-colon  produces  a  retention  in  the  cecum  and  ascend- 
ing colon.     Briefly,  the  first  type  is  atonic,  the  second  is  spastic. 

Skinner^^  notes  four  types  of  constipation  which  are  non- 
organic and  purely  functional.     These  are  as  follows : 

1.  Hypermotihty  of  the  proximal  colon  with  increased  anti- 
peristalsis.  Six  hours  after  the  bismuth  meal  its  shadow  may 
reach  as  far  as  the  descending  colon,  but  at  the  end  of  twelve  or 
twenty-four  hours  the  opaque  shadows  in  the  cecal  and  hepatic 
areas  are  increased  in  size  while  there  is  little,  if  any,  filling  of  the 
pelvic  colon. 

2.  The  cecal  type,  with  slow  filling  of  the  cecum  and  long  re- 


CHRONIC    INTESTINAL    STASIS    AND    CONSTIPATION  501 

tention  of  the  bismuth  there,  often  associated  with  a  history  of 
recurring  appendicitis  in  the  male,  and  ovarian  or  tubal  symp- 
toms in  the  female. 

3.  The  atonic  type,  with  ptosis  of  the  colon,  including  the 
hepatic  and  splenic  flexures.  Bismuth  residues  may  be  found  in 
the  ileum  up  to  twenty-eight  hours  after  the  meal  and  in  the 
colon  up  to  fourteen  days. 

4.  Rectal  constipation.  The  bismuth  reaches  the  pelvic 
colon  in  the  usual  length  of  time  (about  twenty-four  hours),  but 
the  fecal  residue  collects  in  the  sigmoid  and  rectum  from  the 
failure  of  the  individual  to  carry  out  a  rational  rectal  hygiene. 

During  the  past  four  years  we  have  examined  several  hundred 
cases  of  constipation  with  the  opaque  meal  or  enema  or  both. 
In  many  instances,  notwithstanding  an  emphatic  clinical  history, 
the  roentgen  findings  were  trivial  and  valueless,  or  even  utterly 
negative.  In  some  cases  the  information  derived  from  the  x-ray 
appeared  to  be  worth  while.  Although  the  examinations  were 
thorough,  no  obstructive  kinks  were  found,  nor  were  any  dis- 
covered by  the  surgeon  in  those  cases  which  were  explored. 
Angulations  of  the  bowel  were  noted  repeatedly,  and  in  certain 
planes  of  view  these  sometimes  seemed  to  be  acute  and  potentially 
obstructive,  but  when  observed  from  another  direction  the  course 
of  the  bowel  was  seen  to  be  curved  instead  of  angular  and  no 
stenosis  existed.  The  tremendous  variance  of  opinion  among 
observers  as  to  the  frequency  of  kinks  indicates  widely  different 
conceptions  of  this  condition. 

In  several  of  the  cases  coming  to  operation,  the  surgeon  found 
adhesions  of  varying  extent  as  a  result  of  former  interventions. 
In  one  or  two  instances  adhesions  were  present  although  no  pre- 
vious operation  had  been  performed.  Definite  roentgenologic 
signs  of  adhesions  were  lacking,  as  a  rule,  even  when  a  former 
laparotomy  had  been  done,  and  the  presence  of  adhesions  was 
presumable. 

Quite  often  the  constipated  colon,  as  seen  with  the  opaque 
clysma  showed  evidences  of  atony  (Fig.  469).  The  colon  was 
broad,  either  in  its  proximal  half  or  throughout;  its  outline  was 


502  CHRONIC    INTESTINAL    STASIS    AND    CONSTIPATION 

abnormally  smooth,  the  haustra  being  slow  to  appear  and  only 
slightly  marked;  its  length  was  increased  by  redundancy  of  the 
distal  segments;  its  capacity  was  augmented  so  that  additional 
quantities  of  the  enema  were  required  to  fill  it.  From  the  roent- 
genologic standpoint  these  proofs  of  atony  could  hardly  be 
stronger. 


Fig.  469. — Redundant,  atonic  colon.     History  of  severe  constipation.     Examination 

by  enema.     No  operation. 


On  the  other  hand,  though  less  often,  a  directly  opposite  con- 
dition was  noted,  namely  hypertonus  or  spasticity  (Fig.  470). 
The  colon  w^as  narrow  and  deeply  scalloped  with  haustra, 
especially  beyond  the  hepatic  flexure;  it  was  usually  short,  and 
less  than  the  customary  amount  of  the  enema  was  needed  to  fill 
it.  It  must  be  granted  that  neither  atony  nor  spasticity  of  the 
colon  necessarily  betokens  constipation,  but  the  finding  of  either 
in  association  with  stasis  ought  to  have  considerable  bearing  on 
the  treatment. 


CHRONIC    INTESTINAL   STASIS    AND    CONSTIPATION  503 

We  have  been  unable  to  confirm  any  consequential  relation- 
ship either  of  ptosis  or  the  so-called  insufficiency  of  the  ileocolic 
valve  to  stasis. 

It  might  be  said  that  the  barium-meal  test  of  motility  in 
stasis  is  an  elaborate  method  of  confirming  the  patient's  state- 
ment that  he  is  constipated.  However,  besides  this  confirma- 
tion, which  is  sometimes  expedient,  the  meal  may  show  not 


Fig.  470. — Spasticity  of  the  colon  distal  from  the  hepatic  flexure.  Examination  by 
enema.  Marked  constipation.  At  operation  a  small,  subacutely  inflamed  appendix 
was  found,   without   adhesions.      Colon  negative. 

only  the  fact  of  delay,  but  the  region  in  which  the  delay  is 
greatest.  As  has  been  stated  elsewhere,  the  meal  should  be 
given  without  previously  purging  the  patient  or  requiring  him  to 
fast,  since  it  is  desired  to  show  the  progress  of  the  fecal  current 
under  usual  circumstances.  The  meal  which  we  employ  is  a 
mixture  of  barium  with  cereal,  the  same  as  is  used  for  testing 
gastric  motility.  It  is  given  to  the  patient  at  5  p.m.  and  the 
first  examination  is  made  next  morning  at  8  o'clock.     Subse- 


504  CHRONIC    INTESTINAL    STASIS    AND    CONSTIPATION 

quent  examinations  are  made  at  intervals  of  twenty-four  hours, 
or  more  frequently  if  preferred. 

Taking  a  feM"  of  the  patients  operated  on  as  examples,  the 
bulk  of  the  barium  meal  was  still  in  the  ileum  at  seventeen  hours 
in  one,  at  twenty-five  hours  in  another.  Retention  in  the  colon 
atseventy-two  hours  or  longer  was  observed  in  several  instances. 


Fig.  471. — Two  years  previouslj^  this  patient  had  been  operated  upon  elsewhere 
because  of  paroxysmal  pain  in  the  right  lower  abdominal  quadrant — appendectomy, 
colopexy,  longitudinal  plication  of  ascending  colon.  Within  a  month  the  pain  recurred 
and  the  stools  had  to  be  kept  liquid  to  avoid  a  stoppage  of  the  bowel  movements. 
Roentgen  examination  by  the  ingested  opaque  meal  showed  a  large  delay  in  the  right 
half  of  the  colon  up  to  95  hours. 

Opera tve  findings:  Tremendous  amount  of  adhesions,  involving  terminal  ileum, 
cecum,  ascending  and  right  half  of  transverse  colon,  without  marked  obstruction,  from 
former  operation. 

Operation:  Resection  3  inches  of  ileum,  cecum,  ascending  and  transverse  colon. 
Pathologist's  report:  Wall  of  intestine  exceedingly  thin,  with  very  little  muscle- 
tissue. 


and  in  one  instance  a  large  amount  of  barium  was  still  in  the 
colon  after  two  weeks.  Retentions  were  noted  in  different  parts 
of  the  colon;  sometimes  chiefly  in  the  cecum  (Fig.  471),  some- 
times in  the  distal  colon  (Fig.  472),  and  occasionally  scattered 
throughout.     Those  of  our  patients  who  were  operated  on  were 


CHRONIC    INTESTINAL    STASIS    AND    CONSTIPATION  505 

explored,  not  solely  because  of  the  roentgen  findings,  but  because 
the  clinical  factors  justified  surgical  intervention.  Often  there 
was  a  history  of  a  previous  operation.  In  some  cases  this  had 
been  done  for  the  rehef  of  stasis,  but  without  success.  In  view 
of  our  own  rather  indecisive  experience  and  the  varying  experience 
of  others  with  the  roentgen  examination  for  stasis,  any  general 
conclusions  can  be  offered  only  with  diffidence.  It  would  seem, 
however,  that  the  greatest  value  of  the  x-ray  consists  not  in 
showing  organic  obstruction  but  in  excluding  it,  and  that,  at 


Fig.  472. — Large  rectal  ampulla  containing  considerable  barium  at  72  hours.  The 
patient  was  very  constipated  and  because  of  this  in  association  with  a  marked  general 
arthritis  he  was  sent  to  operation.  Resection  of  cecum,  ascending  colon  and  right 
fourth  of  transverse  colon.  Neither  the  arthritis  nor  the  constipation  were  relieved  by 
the  operation. 


present,   clinical   considerations  largely  must   determine  both 
diagnosis  and  treatment. 

REFERENCES 

1.  Lane,    W.    A.:  ''Chronic    Intestinal    Stasis."     Surg.,    Gynec.    & 

OhsteL,  1910,  xi,  495-500. 

2.  EiNHORN,   M.:  "Intestinal   Stasis."     Jour.   A.M.A.,   1914,   Ixiii, 

nil. 


506  CHRONIC    INTESTINAL    STASIS   AND    CONSTIPATION 

3.  Bassler,  a.:  ''Discussion  of  the  Surgical  Theories  of  Intestinal 

Stasis."     Jour.  A.M.A.,  1914,  Ixiii,  1469-73. 

4.  Hertz,  A.  F.:  "Chronic  Intestinal  Stasis."     Brit.  Med.  Jour., 

1913,  i,  817-21. 

5.  Daniel,  P.:  "Septic  Infection  Versus  Chronic  Intestinal  Stasis; 

Legality  of  Ileocolostomy  for  Arthritis."  Clin.  Jour.,  1913, 
xH,  305-14. 

6.  Keith,  A.:  "A  New  Theory  of  the  Causation  of  Enterostasis." 

Lancet,  1915,  ii,  371-75. 

7.  MoYNiHAN,    B.    G.    A.:  "Intestinal    Stasis."     Surg.,    Gynec.    & 

Ohstet.,  1915,  XX,  154-58. 

8.  Jordan,    A.    C:  "Radiography   in    Intestinal    Stasis."    Lancet, 

1911,  ii,  1824-28.  "A  Discussion  on  Alimentary  Toxemia; 
Its  Consequences  and  Treatment."     Proc.  Roy.  Soc.  of  Med., 

1913,  vi,  311-15.  "Intestinal  Stasis."  Practitioner,  1913,  i, 
441-54.     "A  Note  on  Chronic  Intestinal  Stasis."     Clin.  Jour., 

1914,  xliii,  159. 

9.  Pfahler,   G.   E.:  "The  Study  of  Chronic  Intestinal  Stasis  by 

Means  of  the  Roentgen  rays."  Surg.,  Gynec.  &  Ohstet.,  1914, 
xix,  658-63. 

10.  Case,  J.  T. :  "Basic  Considerations  in  the  Roentgen  Study  of 

Intestinal  Stasis."  Pennsylvania  Med.  Jour.,  1915,  xviii. 
"Roentgenologic  Observations  on  the  Functions  of  the  Ileo- 
colic Valve."  Jour.  A.M.A.,  1914,  Ixiii,  1194-98.  "A  Critical 
Study  of  Intestinal  Stasis,  Including  New  Observations  and 
Conclusions  Respecting  the  Causes  of  Ileal  Stasis."  Surg., 
Gynec.  &  Ohstet.,  1914,  xix,  592-600. 

11.  Brown,  P.:  "A  Roentgenological  Consideration  of  the  Relation 

of  Individual  Type  to  Intestinal  Stasis."  Bos.  Med.  &  Surg. 
Jour.,  1914,  clxxi,  581-87. 

12.  Cole,  L.  G. :  "Ileal  Stasis."     Canada  Med.  Assn.  Jour.,  1914,  iv, 

972-78. 

13.  Hertz,  A.  F.:  "Chronic  Intestinal  Stasis."     Brit.  Med.  Jour., 

1913,  i,  817-21. 

14.  Mixter,   S.  J.:  "The  Intestinal  Tract."     Jour.  A.M. A.,   1915, 

Ixv,  1607-10. 

15.  Coffey,  R.  C:  "The  Principles  Underlying  the  Surgical  Treat- 

ment of  Gastro-intestinal  Stasis,  Due  to  Causes  Other  than 
Strictural  or  Ulcerative  Conditions."     Surg.,  Gynec.  &  Ohstet., 

1912,  XV,  365-429. 

16.  Hertz,  A.  F.:  "Constipation  and  Allied  Intestinal  Disorders." 

London,  Frowde,  1909. 


CHRONIC    INTESTINAL   STASIS   AND    CONSTIPATION  507 

17.  ScHWARz,    G.:  "Klinische    Roentgendiagnostik    des    Dickdarms 

und  ihre  physiologischen  Grundlagen."     1914,  Springer,  Ber- 
lin, 61-71. 

18.  Skinner,  E.  H.:  "The  X-ray  Examination  in  Habitual  Constipa- 

tion."    Missouri  State  Jour.  Med.,  1913-14,  x,  51-7. 


CHAPTER  XXVII 
CHRONIC  APPENDICITIS 

While,  for  manifest  reasons,  acute  appendicitis  seldom^comes 
within  the  purview  of  the  roentgenologist,  he  has  had  ample 
material  for  study  of  the  subacute  and  chronic  varieties.  At  the 
beginning,  attention  was  directed  chiefly  to  the  demonstration 
of  concretions  in  the  appendix.  Later  it  was  discovered  that  the 
opaque  meal  or  enema  sometimes  entered  the  appendix,  and 
efforts  to  distinguish  between  the  normal  and  abnormal  appendix 
were  thus  stimulated.  Among  early  writers  on  the  subject  was 
Liertz,^  who  reported  a  case  in  which  the  appendix  was  visual- 
ized after  a  bismuth  meal.  Liertz  discussed  stagnation  of  the 
bismuth  in  the  appendix  as  a  possible  sign  of  appendicitis. 
More  recent  contributors  to  the  literature  include  Singer  and 
Holzknecht,-  Case,^  Rieder,^  Groedel,^  George  and  Gerber,^ 
Cohn,'^  Hertz,^  Henselmann^  and  Imboden.i° 

Singer  and  Holzknecht  report  their  findings  in  25  cases  ex- 
amined fluoroscopically  six  hours  after  the  meal.  They  beUeve 
that  the  radiology  of  appendicitis  has  striven  in  the  wrong  di- 
rection, namely,  the  demonstration  of  the  bismuth-filled  appen- 
dix, as  this  is  only  occasional  and  therefore  uncertain.  They 
dwell  upon  tenderness  in  the  appendiceal  region  as  the  chief  sign, 
and  the  location  of  the  appendix  is  determined  not  so  much  by 
visualizing  it  as  by  demonstrating  the  position  of  the  cecum. 
Used  in  this  manner,  they  consider  the  x-ray  of  great  value  in 
differentiating  tenderness  of  the  appendix  from  tenderness  of 
other  organs  in  the  right  iliac  fossa. 

Case  was  able  to  demonstrate  the  appendix  in  one-third  of  a 
large  series  of  cases  examined  by  the  bismuth  meal.  Technically 
speaking,  he  believes  that  it  is  pathological  for  the  contents  of  the 

508 


CHRONIC    APPENDICITIS  509 

colon  to  enter  the  appendix,  but  he  does  not  wish  to  be  under- 
stood as  holding  that  every  appendix  which  permits  the  entry  of 
bismuth  is  in  need  of  surgical  attention.  The  appendix  which 
remains  visible  for  more  than  a  day  or  two  following  the  bismuth 
examination  is,  he  thinks,  in  proportion  to  its  poor  drainage,  a 
dangerous  appendix.  In  those  cases  in  which  he  demonstrated 
the  appendix,  85  per  cent,  had  definite  tenderness  corresponding 
with  the  shadow  of  the  appendix. 

Rieder  enumerates  among  the  roentgen  signs  of  appendicitis, 
the  following:  Stagnation  of  the  meal  in  the  appendix  and  ileo- 
cecal region;  localized  pressure-tender  point;  insufficiency  of 
Bauhin's  valve  (mentioned  by  Dietlen) ;  adhesions  about  the 
appendicular  region;  kinking  or  pulling  up  of  the  appendix;  con- 
cretions in  the  appendix. 

George  and  Gerber  have  succeeded  in  demonstrating  the 
appendix,  either  normal  or  pathological,  in  about  7  out  of  every 
10  patients  examined.  They  state  that  chronic  appendicitis  can 
be  shown  in  two  ways :  first,  by  the  ileal  stasis  which  it  produces ; 
and  second,  by  actual  demonstration  of  the  kinked  and  adherent 
appendix.  To  be  safely  classed  as  real  ileal  stasis,  bismuth 
should  be  present  at  least  twenty-four  hours  or  longer.  ''From 
the  presence  of  marked  ileal  stasis  alone  we  cannot  make  a 
diagnosis  of  chronic  appendicitis,"  they  say,  "but  we  can  some- 
times infer  it."  The  pathological  appendix  may  show  a  bismuth 
mass  which  is  sharply  kinked  in  one  or  more  places.  It  may 
have  adhesions  to  itself,  to  the  cecum,  ileum  or  even  to  the  sig- 
moid. Retrocecal  appendices  can  sometimes  be  shown  dis- 
tinctly, and  will  show  more  clearly  when  some  of  the  bismuth 
has  passed  out  of  the.  cecum.  In  many  instances  bismuth  will 
persist  in  the  lumen  of  the  appendix  for  hours  after  it  is  out  of 
the  cecum  or  ascending  colon.  In  one  of  their  cases  it  persisted 
as  late  as  five  days. 

Cohn  found  the  appendix  to  be  an  especially  mobile  organ. 
Its  movements  consist  not  only  of  a  change  of  position  in  toto 
but  various  alterations  of  its  configuration.  It  does  not  fill 
immediately  upon  the  entrance  of  material  from  the  small  intes- 


510  CHRONIC    APPENDICITIS 

tine  into  the  colon,  and  it  can  be  concluded  therefore,  that  the 
retrograde  movements  of  the  colon  are  an  important  factor  in  its 
filling.  While  the  colon  is  full  the  appendix  can  be  seen  to  fill 
and  empty  several  times.  Emptying  may  be  retarded,  and  it 
may  retain  opaque  matter  long  after  the  colon  is  evacuated. 

Hertz  believes  that  the  appendix  can  be  shown  in  half  of  all 
persons  examined.  The  presence  of  adhesions  can  be  deter- 
mined. To  show  concretions  the  patient  should  be  rayed 
before  giving  the  meal.  Chronic  appendicitis,  he  insists,  is  one 
of  the  most  common  causes  of  enterospasm,  the  colon  often 
being  narrowed  and  spastic  in  places. 

For  examination  of  the  appendix,  Imboden  places  the  patient 
in  a  horizontal  position  with  the  tube  under  the  table  and  the 
fluoroscopic  screen  on  the  abdomen.  Means  of  palpation  are 
most  essential;  Imboden  prefers  using  the  gloved  hand  and  a  4- 
inch  gauze  bandage-roll.  The  vertical  and  Trendelenburg  posi- 
tions should  also  be  used  in  determining  fixation.  Far  more  ap- 
pendices can  be  visualized  by  the  opaque  meal  than  by  the  enema. 
Other  points  which  he  mentions  are  as  follows:  The  patho- 
logic effects  of  inflammation  of  the  appendix  are  peritoneal 
adhesions,  obliteration  or  strictures  of  the  lumen,  and  the 
presence  of  concretions.  The  last  of  these  can  be  occasionally 
demonstrated  by  the  x-ray,  and  the  other  three  conditions  may 
be  sometimes  inferred  from  the  following  manifestations :  Drain- 
age, position  and  direction,  kinks  or  obliteration,  size,  length  and 
caliber,  mobility  and  points  of  tenderness.  The  mere  presence 
of  some  of  the  opaque  meal  in  the  appendix  is  no  indication  of 
chronic  disease.  Delay  in  emptying  beyond  twenty-four  hours 
after  the  cecum  is  empty,  or  after  vigorous  catharsis,  or  if  de- 
layed emptying  is  associated  with  a  distinct  area  of  tenderness,  is 
to  be  regarded  with  suspicion.  Chronic  disease  is  not  dependent 
upon  position  of  the  appendix  but  is  more  often  found  in  the 
following  positions :  Posterior  and  external  to  the  cecum  with  the 
distal  end  directed  upward  and  meeting  within  the  peritoneal 
cavity;  posterior  and  external  to  the  cecum  and  without  the  peri- 
toneal cavity,  and  directly  behind  the  cecum,  often  just  behind 


CHRONIC    APPENDICITIS 


511 


the  ileocolic  valve.     A  tender  area  located  in  the  course  of  the 
appendix  must  always  be  regarded  as  very  suspicious. 

Recapitulating  the  signs  of  appendicitis  as  noted  by  the  fore- 
going observers,  the  list  comprises: 

1.  Shadows  of  concretions  in  the  appendix. 

2.  Kinking. 

3.  Malposition. 

4.  Adhesions  about  the  appendix  and  cecum. 

5.  Retention  of  barium  in  the  appendix. 


Fig.  473. — Filling  defect,  F,  D,  corresponding  to  a  palpable  tumor, 
large  retrocecal  abscess  was  found. 


At  operation  a 


6.  Ileal  stasis. 

7.  Insufficiency  of  Bauhin's  valve. 

8.  Spasticity  of  the  colon. 

9.  Pressure-tender  point  related  to  the  appendix. 

These  offer  a  wide  selection  of  sign-combinations  according 
to  the  preference  of  the  examiner.  Some  of  them  are  quite 
plausible,  and  with  more  extended  observations  the  roentgen 
diagnosis  of   chronic   appendicitis  may  carry  conviction.     At 


512 


CHRONIC    APPENDICITIS 


present,  however,  certain  reservations  seem  to  be  warranted. 
Fecaliths  are  not  often  sufficiently  dense  to  be  demonstrable  by 
the  x-ray,  but  occasionally  these,  as  well  as  gall-stones  and  other 
foreign  bodies  will  be  revealed,  and  by  using  the  enema  or  meal 
their  intra-appendiceal  situation  can  sometimes  be  determined,  or 
their  differentiation  from  ureteral  calculi,  phleboliths,  or  calcified 
glands  can  be  thus  assisted.     Permanently  kinked  appendices. 


-.ro 


Fig.  474. — Cecum  narrowed  and  irregular  by  filling  defects,  F,  D.  To  the  outer  side 
of  the  contracted  cecum  is  the  shadow  of  a  fecalith,  S,  immediately  above  it  is  a  small 
collection  of  barium.  At  operation  the  concretion  was  found  to  be  the  size  of  a  pecan 
nut  and  Isang  at  the  bottom  ol  a  discharging  sinus,  which  communicated  with  a  post- 
appendiceal  abscess. 

may  perhaps  be  pathologic;  likewise  permanent  malpositions, 
especially  the  retrocecal,  suggest  pathology.  In  this  connection, 
however,  Cohn's  statement  that  the  appendix  tends  to  change  its 
position  and  configuration  must  be  considered.  Definite  fixa- 
tion of  the  appendix  or  of  the  cecum  can,  of  course,  be  attributed 
to  inflammatory  adhesions ;  but  findings  in  this  respect  are  often 
illusive.  Whenever  barium  or  bismuth  enters  the  appendix,  the 
length  of  time  it  may  be  retained  there,  within  normal  limits,  is 


CHRONIC    APPENDICITIS 


513 


problematic;  Cohn  asserts  that  the  appendix  fills  and  empties  in- 
termittently as  long  as  the  meal  remains  in  the  cecum.  Mere 
visualization  of  the  appendix  is  not  evidence  of  appendicitis; 
since  chronic  appendicitis  tends  to  an  obliteration  of  the  lumen, 
failure  to  visualize  the  appendix  should  be  the  more  suggestive. 
Just  when  chronic  appendicitis  can  be  inferred  from  the  presence 
of  ileal  stasis  is  not  stated  by  the  authors  cited,  and  ileal  stasis  un- 
doubtedly has  other  causes  also.     Insufficiency  of  the  ileocolic 


Fig.  475. — Cecum,  C,  distorted  by  adhesions  from  a  chronic  appendicitis. 


valve,  as  demonstrated  by  the  enema,  has  been  meaningless  in 
our  experience.  Spasticity  of  the  colon  has  other  causes  besides 
appendicitis.  Pressure-pain  points  over  the  visualized  appendix 
or  in  close  relation  to  the  visualized  cecum,  are  more  significant 
than  the  clinical  sign  of  tenderness  at  the  McBurney  point. 
Without  this  tenderness  all  the  other  signs  enumerated  lose  much 
of  their  persuasiveness. 

Many  patients  sent  for  roentgen  examination  have  symptoms 
suggesting  a  lesion   either  of   the   stomach,   duodenum,   gall- 


514 


CHRONIC    APPENDICITIS 


Fig.  476. — Cecum  displaced  upward  and  to  the  left  by  an  old  abscess  of  the  appendix. 


f  Fig.  477. — Barium-filled  appendix,  A,  tender  to  palpation  and  not  freely  movable. 
At  operation  the  appendix  was  found  to  be  large  and  adherent.  A  Meckel's  diverti- 
culum, three  inches  long,  situated  two  feet  above  the  ileo-cecal  valve,  was  also  found. 


CHRONIC    APPENDICITIS 


515 


bladder  or  appendix,  but  with  suspicion  equally  divided.     When 
by  the  roentgen  examination  the  stomach  and  duodenum  can 


Fig.  478. — Barium-filled  appendix,  A.     Fecal  concretions  were  found  in  the  appendix 

at  operation. 


Fig.  479. — Barium-filled  appendix  marked  by  arrow.     Concretions  found  at  operation. 

reasonably  be  excluded,  the  x-ray  has  given  its  most  valuable 
service  and  should  not  as  yet  be  expected  to  go  much  further. 


516 


CHRONIC    APPENDICITIS 


In  fortunate  instances  the  ray  may  positively  convict  the  gall- 
bladder; or  the  combined  clinical  and  roentgen  findings  may 
favor  either  the  gall-bladder  or  the  appendix,  but  at  present 
often  only  surgical  exploration  can  decide  between  them  justly. 


Fig.  4S2. 
Figs.  480,  481,  482,  483.— Visualized  appendices.     No  operation. 

On  the  whole,  the  value  of  the  roentgen  signs  of  appendicitis 
appears  to  depend  not  only  upon  the  intensity  of  the  examiner's 
endeavor,  but  also,  to  some  extent,  upon  the  degree  of  his  en- 


CHRONIC    APPENDICITIS 


517 


thusiasm.  Inasmuch  as  few  normal  appendices  have  been 
found  by  surgeons  or  pathologists,  the  diagnosis  of  appendicitis 
upon  any  grounds  whatever  is  not  at  all  hazardous,  but  the 
novice  should  make  sure  that  the  appendix  has  not  pre- 
viously been  removed,  lest  he  mistake  barium  in  the  ileum  for  a 
shadowed  appendix  and  draw  his  conclusions  accordingly. 

Our  own  observations  have  included  cases  of  retrocecal  ab- 
scess, probably  of  appendiceal  origin  (Fig.  473),  fistulous  abscess 


Fig.  484. — Chronic  appendicitis  found  at  operation. 

examination. 


No  evidence  in  the  Roentgen 


with  shadowed  concretion  (Fig.  474),  distortion  of  the  cecum  by 
adhesions  from  a  chronic  appendicitis  (Fig.  475),  and  displace- 
ment of  the  cecum  upward  and  to  the  left  as  a  result  of  an  old 
abscess  of  the  appendix  (Fig.  476).  While  the  roentgen  evidence 
in  these  cases  was  strongly  indicative  of  a  lesion,  it  was  not  alone 
decisive  as  to  the  nature  of  the  process,  except  in  the  case  with  a 
fecal  concretion.  Spasticity  of  the  distal  colon,  in  cases  which 
ta  operation  proved  to  be  chronic  appendicitis,  was  noted  suffi- 


518 


CHRONIC    APPENDICITIS 


ciently  often  to  occasion  remark,  but,  while  interesting,  this  could 
not  be  considered  diagnostic.  In  a  small  percentage  of  the  co- 
lons examined,  the  appendix  was  visualized  by  the  enema. 
Some  of  these  cases  went  to  operation  and  a  chronic  appendicitis 
was  found  (Fig.  477);  in  two  instances  the  appendix  contained 
fecaliths,  but  the  roentgenogram  did  not  show  their  presence 
(Figs.  478  and  479).     Unoperated  cases  with  a  visualized  appen- 


FiG.  485. — Chronic  appendicitis  found  at  operation.     Roentgen  examination  negative. 

dix  are  illustrated  in  Figs.  480,  481,  482  and  483.  In  scores  of 
patients  operated  on  for  chronic  appendicitis  the  roentgen  ex- 
amination of  the  colon  was  negative  (Figs.  484  and  485). 


REFERENCES 

1.  LiERTZ,    R. :  "Die   radiographische   Darstellung   des   Wurmfort- 

satzes."     Deutsch.  Med.  Wchnschr.,  1910,  ii,  1269-70. 

2.  Singer,  G.  and  Holzknecht,  G.:  "  Radiologische  Anhaltspunkte 

zur  Diagnose  der  chronischen  Appendizitis."     Munch.   Med. 
Wchnschr.,  1913,  ii,  2659-2664. 


REFERENCES  519 

3.  Case,  J.  T.:  "Roentgen  Examination  of  the  Appendix."     New 

York  Med.  Jour.,  1914,  c,  161-67. 

4.  RiEDER,    H.:  "Zur    Rontgenuntersuchung    cles    Wurmfortsatzes, 

besonders  bei  Appendizitis."  Munch.  Med.  Wchnschr.,  1914, 
ii,  1492-94. 

5.  Groedel,   F.   jM. :  ''Die  rontgenologische  Darstellung  des  Proc- 

essus vermiformis."     Munch.  Med.  Wchnschr.,  1913,  i,  744-45. 

6.  George,  A.  W.  and  Gerber,  I.:  ''The  Value  of  the  Rontgen 

Method  in  the  Study  of  Chronic  Appendicitis  and  Inflamma- 
tory Conditions,  Both  Congenital  and  Acquired,  about  the 
Cecum  and  Terminal  Ileum."  Surg.,  Gynec.  &  Obstet.,  1913, 
xvii,  418-27. 

7.  CoHN,  M.:  "DerWurmfortsatz  iniRontgenbilde."     Deutsch.Med. 

Wchnschr.,  1913,  i,  606-08. 

8.  Hertz,  A.  F. :  "X-ray  Diagnosis  of  Gastro-intestinal  Conditions, 

with  Especial  Reference  to  Appendicitis."  Arch.  Roentgen 
Ray,  1914,  xix,  249-55. 

9.  Henselmann,    a.:  "Kleine    rontgenologische    A^orrichtung    zur 

Erzeugung  von  Wurmfortsatzbildern."     Berl.  klvn.   Wchnchr., 
1914,  ii,  1517-18. 
10.  Imboden,  H.  yi. :  ''Roentgen  Diagnosis  of  Lesions  of  the  Vermiform 
Appendix."     Amer.  Jour.  Roent.,  1915,  ii,  581-91. 


CHAPTER  XXA  III 

MISCELLANEOUS  LESIONS  AND  CONDITIONS  OF  THE  COLON 

Polyposis. — Relatively  few  cases  of  extensive  polyposis  of  the 
colon  have  been  recorded.  Doering^  in  1907,  collected  52  cases, 
including  2  of  his  own.  Recently  Soper-  has  collected  8  addi- 
tional cases  and  reports  1  personally  observed.  Soper' s  case 
was  examined  bv  the  x-rav  after  colectomv.  Idiu  no  mention  is 


Fig.  486. — Polj-posis  of  the  colon. 

made  of  a  roentgen  examination  in  any  of  the  other  cases  avail- 
able for  reference. 

Of  the  recent  cases  seen  in  the  Mayo  Clinic,  one  was  submitted 
to  roentgen  inspection.  The  patient,  a  man  aged  30.  had  had 
diarrhea  for  a  year,  with  abdominal  pain  and  distress.  A  tender, 
freely  movable,  sausage-shaped  mass  could  he  palpated  in  the 
epigastrium.  The  proctoscopic  examination  revealed  a  general- 
ized mucosal  inflammation,  becoming  granular  higher  up.  The 
stools  contained  pus  and  red  blood  cells,  but  no  parasites. 

520 


ANOMALIES    OF    MIGRATION    AND    ROTATION 


521 


The  two  roentgenograms  herewith  show  the  condition  as  seen 
by  the  x-ray.  The  first  examination  (Fig.  486)  showed  appar- 
ent obstruction  in  the  pelvic  colon.  At  the  second  examination 
the  entire  colon  was  filled  but  was  irregularly  mottled  through- 
out, and  this  was  doubtless  due  to  the  multiple  papillomatous 
growths  (Fig.  487) .  .^ 

At  operation  the  colon,  from  the  hepatic  flexure  on,  showed 
marked  thickening  of  its  walls,  and  the  vessels  were  injected. 
An  ileostomy  was  made.     Four  and  a  half  months  later,  the 


Fig.  487. — Polyposis  of  the  colon. 

patient  having  gained  weight  and  strength,  a  second  operation 
w^as  performed.  This  time  a  colectomy,  complete  save  for  about 
12  inches  of  sigmoid  and  rectum,  was  done.  The  exsected  bowel 
was  found  to  contain  multiple  polyps,  beginning  in  the  ascending 
colon  and  extending  to  the  middle  of  the  sigmoid. 

Figure  488  is  the  photograph  of  a  specimen  from  the  colon  in 
a  similar  case  of  polyposis. 

Anomalies  of  Migration  and  Rotation. — ConnelP  points  out 
that  in  its  normal  development  the  ileocecal  juncture  migrates 


522        MISCELLANEOUS  LESIONS  AND  CONDITIONS  OF  COLON 

from  below  upward  and  to  the  left  to  form  the  splenic  flexure, 
crosses  the  abdomen  to  the  hepatic  flexure  where  it  rotates  on  its 
long  axis,  descends,  and  is  fixed  in  its  usual  location  in  the  right 
iliac  fossa.  This  complicated  embryological  maneuver  is  gener- 
ally spoken  of  as  ''rotation  of  the  cecum,"  but  Connell  shows 
that  it  comprises  three  distinct  elements,  viz.,  migration,  rota- 
tion, and  fixation.     By  migration,  he  means  the  journey  of  the 


Fig.  488. — Photograph  of  specimen  from  colon.     Polyposis. 

ileocecal  juncture  up  the  left  side,  across,  and  down  the  right 
side  of  the  abdominal  cavity.  Rotation  should  be  confined  to 
the  actual  axial  rotation  of  the  ileocecal  juncture  through  an 
angle  of  180  degrees.  Fixation  means  the  blending  of  the  pos- 
terior colonic  peritoneum  with  the  prerenal  parietal  peritoneum. 
Migration,  he  states,  may  be  incomplete  or  delayed.  The 
commonest  arrest  of  migration  occcurs  at  some  point  between 


ANOMALIES    OF   MIGRATION   AND    ROTATION  523 

the  hepatic  flexure  and  the  usual  location  of  the  cecum  in  the 
right  iliac  fossa.  It  may  occur  at  the  hepatic  flexure,  or  distal 
to  it,  either  before  or  after  fixation.  If  before  fixation,  the  cecum 
may  fall  back  to  the  left  iliac  fossa.  This  is  unusual,  but  may 
account  for  cases  of  left-sided  appendicitis  in  which  the  viscera 
are  not  transposed.  With  delayed  migration  the  cecum  may  be 
in  its  normal  position,  but  adventitious  bands  or  membranes  may 
suggest  that  fixation  began  before  migration  was  complete. 


Fig.  489. — High  cecum.     Possible  arrest  of  migration.     No  operation. 

Non-rotation  may  occur  with  incomplete  migration  before 
the  development  of  the  hepatic  flexure,  or,  less  frequently,  it  may 
persist  after  formation  of  the  hepatic  flexure  and  ascending  colon. 
In  these  instances  the  terminal  ileum  enters  the  cecum  from  be- 
hind or  from  the  right  side.  With  excessive  rotation,  which  may 
be  even  as  much  as  270  degrees,  the  ileum  enters  the  cecum  in 
front. 

Fixation  may  be  absent,  or  excessive,  or  improper  surfaces 
may  be  fused.  The  cecum  mobile  is  due  to  an  absence  of  fixa- 
tion.    Connell  suggests  that  the  Lane  kink  may  be  the  result 


524        MISCELLANEOUS  LESIONS  AND  CONDITIONS  OF  COLON 

of  anomalous  fixation,  while  Jackson's  pericolic  membrane  may 
be  due  to  anomalous  fixation,  excessive  rotation,  or  delayed 
migration. 

Apart  from  the  question  of  Lane's  kink  and  Jackson's  mem- 
brane, we  have  encountered  occasional  instances  of  incomplete 
migration.  Now  and  then  we  have  noted  a  high  placed  cecum 
with  a  very  short  ascending  colon,  due  perhaps  to  incomplete 
migration  (Figs.  489  and  490j.     Less  often,  the  arrest  of  migra- 


FiG.  490. — High    placecLlcecum.     Possible    arrest       ofmigration.     No    operation. 

tion  is  strikingly  evident,  as  in  Fig.  49 L     In  Fig.  492  the  cecum 
is  fixed  at  the  site  ordinarily  occupied  by  the  hepatic  flexure. 

Cecum  Mobile. — In  1908,  AVilms^  announced  his  theory  that 
in  many  cases  of  so-called  chronic  appendicitis  the  real  cause  of 
the  pain  and  tenderness  at  McBurney's  point  was  a  long,  mov- 
able cecum.  The  pain,  he  suggested,  was  produced  by  twisting 
and  stretching  of  the  nerves  in  the  mesentery,  and  this  accounted 
for  the  failure  of  appendicectomy  to  relieve  the  symptoms. 
Wilms,  therefore,  advised  fixation  of  the  cecum  also,  and  reported 
satisfactory  results  in  about  40  cases.     Since  his  contribution, 


CECUM    MOBILE 


525 


cecum  mobile  has  been  frequently  discussed  by  others,  being 
either^indorsed  or  disputed  as  a  disease-entity.  Case^  states  that 
it  is  easily  recognizable  roentgenologically.  Associated  with 
abnormal  mobility,  varying  degrees  of  dilatation  and  elonga- 
tion, there  is  stasis  in  the  cecum  long  after  the  remainder  of  the 
colon  has  been  emptied.  Great  tenderness  is  often  elicited  by 
palpation  over  the  cecal  shadow.  He  goes  on  to  say  that  this 
dilated,  "elongated  cecum  is  not  always  mobile,  being  often  asso- 


FiG.  491. — Non-migration  of  colon.  Plate  made  twenty-four  hours  after  in-gested 
meal  (Dr.  J.  H.  Selby).  The  colon  is  almost  completely  visualized  and  lies  entirely  to 
the  left  of  the  spine.     The  arrows  indicate  the  flexures.     Confirmed  by  operation. 

ciated  with  adhesions.  Hausmann'^  discusses  the  subject  ex- 
haustively, and  gives  the  roentgenograms  of  several  cases,  show- 
ing extraordinary  mobility  of  the  cecum.  Beclere  and  MerieF 
say  that  abnormal  mobility  of  the  cecum,  which  has  been  called 
cecum  mobile  by  analogy  to  abnormal  displacement  of  the 
kidney,  is  not  really  a  morbid  condition.  It  is  compatible  with 
perfect  health,  and  appears  only  to  be  a  mechanical  condition 
capable  in  association  with  other  causes,  of  favoring  the  develop- 


526        MISCELLANEOUS  LESIONS  AND   CONDITIONS  OF  COLON 

merit  of  certain  functional  troubles.  While  its  radiologic  study- 
is  of  interest,  they  say,  the  findings  obtained  are  never  sufficient 
to  recommend  operative  intervention.  Schwarz^  mentions  a 
case  in  which  he  could  demonstrate  that  the  cecum,  with  its  ab- 
normally wide  and  therefore  readily  filled  appendix,  moved  about 
5  cm.  toward  the  median  line  when  the  patient  was  placed  in  the 
lateral  position.  He  considers  this  to  be  what  Wilms  would  call 
cecum  mobile. 


Fig.  492. — Cecum  fixed  high  up  in  right  abdomen,  due  probably  to  incomplete  migra- 
tion.    No  operation. 

Jackson's  Membrane. — Jackson,^  in  1909,  described  a  series 
of  cases  in  which  the  proximal  portion  of  the  colon  was  closely 
invested  with  a  delicate,  transparent,  vascular  membrane  or  veil, 
somewhat  resembling  the  arachnoid,  or  a  thin  pterygium. 
Usually  the  cecum  was  not  involved,  and  the  membrane  ex- 
tended from  the  cecum  toward  or  up  to  the  hepatic  flexure;  in 
one  instance  it  passed  across  to  the  transverse  colon  which  was 
drawn  down  parallel  with  the  ascending  colon.     In  advanced 


TRANSPOSITION  527 

and  characteristic  cases  it  seems  to  bind  the  colon  close  to  the 
abdominal  wall,  producing  marked  angulations  of  the  colon,  or 
a  practical  stricture  of  its  lumen.  The  clinical  sydrome  includes 
pain  referred  to  the  whole  right  abdomen,  general  right-sided 
tenderness,  though  frequently  more  marked  at  McBurney's  point 
and  just  below  the  ribs,  constipation,  mucus  in  the  stools,  gas 
distention,  loss  of  weight,  gastric  fermentation,  and  neurasthenia. 
Often  appendicectomy  or  cholecystotomy  has  been  done  with- 
out relief.  In  a  few  instances  Jackson  has  removed  the  mem- 
brane by  careful  dissection,  with  good  results. 

Skinner ^'^  has  discussed  the  roentgen  manifestations  of  Jack- 
son's membrane,  both  in  theory  and  practice.  He  states  that 
there  are  two  favorite  sites  upon  the  ascending  colon  for  pericolic 
bands:  First,  just  below  the  hepatic  flexure,  on  the  ascending 
colon.  This  almost  seems  to  be  an  accentuation  of  the  normal 
mesenteric  attachment.  It  produces  a  filling-defect  in  the  form 
of  a  circular  constriction  of  the  colon,  which  causes  a  partial 
damming  back  of  the  colonic  contents,  with  tenderness  along 
this  portion  of  the  colon.  Second,  a  frequent  pericolic  band 
seems  to  constrict  the  ascending  colon  upon  a  level  with  the 
ileocecal  valve,  producing  a  transverse,  linear  filUng-defect,  and 
this  is  usually  accompanied  by  ileal  adhesions  causing  stasis. 
He  also  shows  the  roentgenogram  of  a  case  of  pericolitis  dextra, 
in  which  the  cecum  lies  in  the  true  pelvis  and  is  loaded  with  bis- 
muth; the  ascending  colon  is  narrow,  spastic  and  poorly  filled; 
the  hepatic  flexure  is  high,  and  stringy  mucous  shadows  are  seen 
in  the  transverse  colon.  Skinner  is  careful  to  point  out  numer- 
ous possible  sources  of  error  in  interpretation,  especially  spasm, 
and  says:  ''The  disposition  to  take  roentgenograms  of  the  ab- 
dominal viscera  at  their  face  value  is  extremely  dangerous,  as 
there  is  probably  nothing  which  lends  itself  so  easily  to  interpre- 
tations of  thought." 

Transposition. — Transposition  of  the  colon  is  an  interesting 
feature  of  the  rare  cases  of  situs  viscerum  inversus  totalis,  and  a 
few  cases  have  been  reported  by  roentgen  observers.     Transpo- 


528        MISCELLANEOUS  LESIONS  AND  CONDITIONS  OF  COLON 

sition  of  the  colon  may  exist  also  without  transposition  of  the 
other  viscera  (Fig.  492a). 

Intussusception. — Two  cases  of  intussusception  in  which  a 
roentgen  examination  was  made  have  been  noted  in  the  literature. 
One  case  reported  by  Lehmann^^  was  that  of  an  eighteen-year- 
old  patient.  Upon  introducing  the  enema  it  flowed  without  in- 
terruption to  about  the  middle  of  the  transverse  colon.     Here  it 


Fig.  492a. — Transposition  of  the  colon,  wliich  is  otherwise  normal.      Confirmed  by  care- 
ful screen  examination.     The  stomach  was  not  transposed,  nor  was  the  heart. 

was  definitely  obstructed,  and,  after  a  little,  the  stream  sent  out  a 
projection  about  1  cm.  broad  along  the  upper  and  lower  borders 
of  the  transverse,  beyond  the  obstruction,  and  between  these 
projections  was  an  area  of  lessened  density  occupied  by  the 
invaginated  small  bowel.  The  invagination  corresponded  ex- 
actly to  the  roentgen  findings. 


HIRSCHSPRUNG  S   DISEASE 


529 


The  other  case,  recorded  by  Groedel,^^  was  of  a  boy  7 
years  of  age.  With  the  enema  the  colon  was  visuahzed  through- 
out and  there  was  a  slight  retrograde  filling  of  the  ileum,  but 
nothing  distinctive  was  seen.  Two  days  later  an  opaque  meal 
was  given.  Eight  hours  afterward  some  of  it  had  passed  into 
the  colon,  but  the  terminal  ileum  was  markedly  dilated,  and 
Groedel  considered  the  picture  typical  of  ileocecal  stenosis.  At 
operation  15  cm.  of  the  bowel  was  found  to  be  invaginated. 


Fig.  493. 


-Megasigmoid.     The  sigmoid  was  found  at  operation  to  be  thin-walled  and 
enormously  distended. 


Hirschsprung's  Disease  (Megacolon)  and  Megasigmoid. — 

Congenital  idiopathic  dilatation  of  the  colon  is  easily  shown  by 
the  x-ray,  and  several  observations  have  been  published.  A 
typical  case  is  that  reported  by  Linde  and  Kleiner.  ^^  The 
child,  a  girl  3H  years  of  age,  was  extremely  constipated  from 
birth,  and  had  never  had  a  bowel  movement  without  an  enema. 
The  abdomen  was  protuberant.  The  roentgenogram  of  the 
enema-filled  bowel  shows  the  entire  colon  to  be  excessively 
broad  and  capacious  and  with  very  little  haustration.  Elonga- 
tion with  dilatation  of  the  sigmoid  (megasigmoid)  appears  to_^be 
more  frequent  than  the  complete  dilatation  of  Hirschsprung 

31 


530       MISCELLANEOUS  LESIONS  AND  CONDITIONS  OF  COLON 

(Beclere  and  Meriel).^^  Figure  493  is  the  roentgenogram  of 
a  case. 

Incompetence  of  The  Ileocecal  Valve. — Insufficiency  of 
Bauhin's  valve,  permitting  a  retrogression  of  the  cecal  contents 
into  the  small  intestine,  has  been  given  considerable  attention 
from  the  roentgenologic  viewpoint  by  Case,^^  Dietlen,^^  Groedel^^ 
and  others. 

Case,  who  began  his  observations  in  1910,  has  found  the  valve 
to  be  incompetent  in  about  one-sixth  of  all  cases  examined  with 
the  enema.  He  uses  an  enema,  made  up  with  either  barium  or 
bismuth,  which  is  warmed  to  a  temperature  of  100°F.,  and  the 
container  is  held  not  higher  than  2  feet  above  the  patient.  For 
the  most  part,  the  patients  examined  were  suffering  from  gastro- 
intestinal symptoms  and  complained  of  constipation.  In  many 
cases  he  has  also  observed  a  reflux  of  ingested  bismuth  from  the 
colon  into  the  ileum.  Case  believes  that  incompetence  of  the 
valve  is  a  significant  abnormality,  and  that  it  is  a  common  cause 
of  ileal  stasis. 

Dietlen  avows  his  belief  that,  while  the  valve  is  incompetent 
in  infants,  it  is  normally  competent  in  children  and  adults.  He 
has  been  able  to  demonstrate  insufficiency,  usually  by  the  enema 
but  occasionally  by  the  ingested  meal,  in  a  number  of  cases. 
Few  of  these  patients  were  operated  upon,  but  there  were  clinical 
or  roentgenologic  signs  of  various  pathologic  conditions  such  as 
chronic  appendicitis,  dilatation  of  the  cecum,  colitis,  extrinsic 
tumors,  perityphlitis  with  adhesions,  obstipation  and  perichole- 
cystitis. In  one  or  two  of  his  cases  the  colon  was  presumably 
normal. 

In  studying  the  ileocolic  valve,  Groedel  uses  1  liter  of  an 
enema  containing  300  gm.  each  of  barium  sulphate  and  bolus 
alba.  After  introducing  the  enema  the  patient  is  allowed  to 
empty  the  bowel  partially  by  natural  defecation  without  un- 
usual effort.  After  this,  if  a  large  portion  of  the  small  bowel  is 
retrogradely  filled,  a  pathologic  condition  of  Bauhin's  valve  may 
be  assumed.  In  the  majority  of  cases,  he  states,  the  cause  is 
either  a  chronic  catarrhal  affection  of  the  cecum,  or  a  chronic 


INCOMPETENCE    OF    THE    ILEOCECAL  VALVE  531 

perityphlitic  process.  Other  causes  include  anatomic  anomalies, 
nervous  disturbances,  dilatation  of  the  ascending  colon,  ulcers 
and  tumors  of  the  valve-ring,  cecum  or  cecal  region. 

Singer  and  Holzknecht^^  noted  incompetence  of  the  valve  in 
numerous  cases  of  obstipation,  and  this  occurred  whether  the 
cecum  was  dilated  or  not. 

The  theory  that  the  ileocolic  valve  is  normally  competent  is 
supported  by  some  of  the  anatomic  and  experimental  studies 
which  have  been  made.  The  work  of  Keith^^  has  been  adduced 
in  corroboration.  A  recent  monograph  by  Rutherford-"  also 
substantiates  this  view. 

Contrary  opinions  regarding  the  competence  of  the  valve  and 
the  significance  of  the  incompetence  shown  by  the  x-ray  have 
been  advanced  by  numerous  authorities.  Some  of  these  are 
frankly  cited  by  Dietlen  and  Case.  Relative  to  the  matter  of 
giving  nutrient  enemata,  it  has  been  shown  that,  at  least  in  cer- 
tain cases,  the  valve  permits  the  entry  of  an  enema  into  the 
ileum.  Senn^^  found  by  experiment  that  air  at  a  pressure  of 
Y4,  to  ly^  pounds  would  overcome  the  resistance  of  the  valve,  and 
thinks  that  this  incompetency  is  caused  by  a  lateral  and  longi- 
tudinal distention  of  the  cecum  which  mechanically  separates 
the  margins  of  the  valve.  Hertz^^  declares  unequivocally  that 
the  ileocecal  sphincter  does  not  prevent  regurgitation  into  the 
ileum,  as,  in  common  with  other  observers,  he  has  seen  a  bis- 
muth suspension  pass  into  the  ileum  when  run  into  the  colon  at 
a  pressure  as  low  as  1  foot  of  water.  There  can  be  no  doubt,  he 
says,  that  the  function  of  the  valve  sphincter  is,  as  Keith  origi- 
nally suggested,  to  prevent  the  contents  of  the  ileum  passing 
too  rapidly  into  the  cecum. 

In  our  own  work,  with  the  enema  given  in  the  manner  de- 
scribed, the  clysma  enters  the  ileum  in  the  great  majority  of  cases 
— probably  three-fourths  of  them.  The  patients  examined  are 
of  the  character  usually  sent  for  the  roentgen  test ;  most  of  them 
have  gastro-intestinal  symptoms  of  some  sort,  and  many  are 
constipated,  but  there  is  also  a  considerable  number  whose 
symptoms  are  found  at  operation  to  be  due  to  various  abdominal 


532        MISCELLANEOUS  LESIONS  AND  CONDITIONS  OF  COLON 

lesions  not  involving  the  bowel,  which  is  normal.  The  incompe- 
tence is  of  all  degrees,  ranging  from  a  trivial  backflow  through 
the  valve  to  an  extensive  filling. of  the  lower  ileum  (Figs.  494, 


Fig.  496.  Fig.  497. 

Figs.  494,  495,  496,  497. — Barium  in  ileum  from  enema. 


495,  496  and  497).  Absolutely  no  relation  has  been  noted  be- 
tween this  insufficiency  and  pathologic  conditions,^  either  in 
general  or  in  particular. 


ENTEROLITHS 


533 


In  the  course  of  abdominal  operations  for  various  conditions, 
the  late  Dr.  E.  H.  Beckman  (Mayo  Clinic)  carefully  examined 
the  ileo-cecal  region  in  a  number  of  cases  which  had  shown  in- 
competence of  the  valve  with  the  opaque  enema,  but  he  found 
no  anatomic  abnormality  to  account  for  it. 

It  is  doubtful  whether  an  enema,  put  into  the  bowel  under 
unphysiologic  conditions,  and  necessitating  at  least  a  slight 
degree  of  hydrostatic  pressure,  would  be  a  fair  test  of  the 
physiologic  competence  of  the  valve.  A  regurgitation  of  the  in- 
gested meal  into  the  ileum,  after  once  passing  the  valve,  would 


Fig.  498. — Barium-coated  scybalse  in  lower  bowel  resembling  concretions. 


theoretically  have  greater  import.  But  whether  this  indi- 
cates merely  an  unimportant  perversion  or  laxity  of  function, 
or  is  significant  of  serious  pathology,  with  possibilities  in  the 
way  of  differential  diagnosis,  remains  to  be  determined. 

Enteroliths. — Besides  the  occasional  presence  of  fecal  con- 
cretions in  the  appendix,  as  mentioned  under  the  latter  subject, 
enteroliths  of  larger  dimensions  are  sometimes  discovered  in  the 


534        MISCELLANEOUS  LESIONS  AND  CONDITIONS  OF  COLON 

intestine.  Pfahler  and  Stamm-^  report  a  case  in  which  the 
x-ray  examination  revealed  an  abnormal  mass,  IM  inches  in 
diameter,  of  slight  opacity,  occupying  the  pelvic,  then  the  iliac 
region.  Injection  of  the  colon  with  an  opaque  enema  showed 
definitely  that  the  mass  was  in  the  cecum;  it  could  be  moved 
about  within  the  cecum  and  ascending  colon.  It  was  partially 
dissolved  by  glycerin  enemata,  passed  into  the  rectum,  and  was 
there  broken  up  with  the  finger  and  removed.  It  proved  to  be 
a  fecahth  consisting  mainly  of  magnesium  phosphate.  In  Fig. 
498  the  barium-covered  scybalae  resemble  concretions. 

Foreign  Bodies. — The  approximate  localization  of  foreign 
bodies  in  the  intestine  is  sometimes  a  matter  of  importance. 
For  example,  when  anastomosis  has  been  made  with  a  Murphy 
button  and  the  exit  of  the  button  is  delayed,  it  is  desirable  to 
know  w^hether  it  has  passed  into  the  colon  or  not.  This  can  be 
done  conveniently  by  giving  an  opaque  clj^sma  and  noting 
whether  or  not  the  shadow  of  the  button  is  enveloped  in  that  of 
the  enema.  ^The  method  is  applicable,  of  course,  in  the  case  of 
any  opaque  foreign  body. 

Figures  499  and  500  illustrate  a  case  in  which  a  dental  plate 
in  the  transverse  colon  was  localized  by  an  enema. 

Fistulae. — Following  operations  on  the  intestine  or  as  a  re- 
sult of  disease,  external  fistulse  sometimes  develop,  and  it  may 
be  desirable  to  know  the  exact  part  of  the  bowel  in  which  the 
fistulse  originate,  as  w^ell  as  the  extent  of  their  ramifications. 
Ordinarily  this  can  be  learned  by  injecting  the  fistula  with  a 
bismuth-petrolatum  paste.  The  paste  may  enter  the  bowel  in 
sufficient  quantity  to  \dsualize  a  segment  of  it,  and  thus  show 
the  point  of  communication  (Fig.  501);  if  not,  the  colon  may 
also  be  filled  with  an  opaque  enema. 

In  occasional  instances  it  may  be  doubtful  whether  or  not  a 
suppurating  sinus  following  an  abdominal  operation  has  any 
connection  with  the  bowel.  In  such  cases  we  have  made  effect- 
ive use  of  a  procedure  suggested  by  E.  S.  Judd.  The  sinus  is 
thoroughly  injected  with  the  paste,  the  external  opening  is  sealed 
with  gauze  and  adhesive  plaster,  and  a  roentgenogram  is  made. 


FISTULA 


535 


Fig.  499. — Dental  plate,  P,  in  bowel.     Location  uncertain. 


Fig.  500.-— Same  case  as  in  499,  twenty-four  hours  later.     The  enema  locates  the  plate, 
P,  in  the  transverse  colon.     Subsequently,  the  plate  was  passed  in  the  stool. 


536       MISCELLANEOUS  LESIONS  AND  CONDITIONS  OF  COLON 


Fig.  501." — Fecal  fistula  injected  with  thick  barium-pap,  showing  its  ramifications  and 
point  of  communication  with  the  colon. 


Fig.  501a. 


BECTTJM  537 

A  second  roentgenogram  is  taken  twenty-four  hours  later,  after 
purging  the  patient  ^"ith  oil.  If  the  second  plate  indicates  a 
diminution  of  the  paste,  as  shown  by  changes  in  the  sinus-shadow, 
it  is  safe  to  assume  that  a  fistulous  connection  with  the  bowel 
exists;  otherwise  not. 

Fig.  501  o  illustrates  an  interesting  post-operative  condition. 
Following  an  operation  on  the  left  kidney  fifteen  years  ago  the 
patient  developed  a  suppurating  sinus  which  has  continued 
ever  since.  An  attempt  to  close  it  by  operation  ten  years  ago 
failed.  Both  these  operations  were  done  elsewhere.  Another 
attempt  was  made  here  in  Xovember,  1916.  During  this  latter 
operation  a  small  amount  of  a  solution  of  methylene  blue  was 
injected  iato  the  fistula,  and  some  of  it  immediately  appeared 
in  the  patient's  mouth.  Because  of  insuperable  difficulties  the 
operation  was  abandoned  and  treatment  with  Beck's  paste 
was  directed.  After  the  first  injection  of  the  paste,  the  patient 
was  sent  for  roentgen  examination.  The  roentgenogram  ^Fig. 
oOla)  shows  the  extensive  suius  ramifications.  Some  of  the 
paste  has  entered  the  colon  and  the  stomach  is  completely 
filled  by  it. 

Rectum. — Direct  inspection  of  the  rectum  through  the  proc- 
toscope is.  im.der  ordinary  circumstances,  so  far  superior  to  other 
methods  of  examination  that  the  aid  of  the  x-ray  is  rarely  called 
for.  Occasionally,  however,  in  the  case  of  a  rectal  cancer, 
more  expUcit  information  is  desired  as  to  the  upper  limit  of 
involvement,  and  this  is  obtainable  by  the  roentgen  examina- 
tion. An  instance  is  shown  in  Fig.  502.  We  have  had  an  in- 
teresting case  in  which  a  fecahth  obstructing  the  upper  rectum 
was  first  detected  by  the  x-ray  (Fig.  503),  no  digital  examina- 
tion having  been  made. 

The  Colon  after  Operation. — When  there  are  clinical  indica- 
tions of  acute  intestinal  obstruction  following  laparotomy,  the 
question  arises  as  to  the  fact  of  obstruction  and  its  probable  site, 
and  exceptionally  a  roentgen  examination  may  be  permissible. 
In  some  of  these  instances  Case--  has  found  it  unnecessary  to 
administer  any  opaque  material,  roentgen  observations  being 


538       MISCELLANEOUS  LESIONS  AND  CONDITIONS  OF  COLON 


Fig.  502. — Cancer  of  upper  rectum.     Filling  defect,  F.  D. 


Fig.  503. — Large  fecalith,  F,  in  rectum.     Patient  aged  two  years. 


THE  COLON  AFTER  OPERATION 


539 


made  possible  by  the  gas-distention  of  the  intestine.  With 
acute  colonic  obstruction  the  haustral  markings  and  the  distri- 
bution of  the  gas  were  sufficient  to  identify  the  colon,  while  in 
acute  obstruction  of  the  small  bowel  its  serrated  contour  and  the 
parallel  arrangement  of  its  coils  were  equally  characteristic. 
When  circumstances  allow  the  administration  of  a  barium  meal 
or  enema  the  diagnosis  can  be  made  with  greater  certainty. 

Recurring  cancer  of  the  colon,  after  resection  of  the  original 
growth,  can,  of  course,  be  shown   by   the  x-ray.     Numerous 


Fig.  504. — Colon  after  ileosigmoidostomy. 


short-circuiting  operations  such  as  ileo-sigmoidostomy  and 
ceco-sigmoidostomy  are  being  performed,  not  only  for  the  pallia- 
tion of  otherwise  inoperable  conditions,  but  also  for  stasis. 
After  any  of  these  the  functional  results  can  be  studied  by  the 
x-ray,  frequently  with  profit  and  always  with  interest.  Roent- 
gen observers  agree  without  exception  that  after  any  anastomo- 
sis which  leaves  a  blind  sac  of  the  colon  proximal  to  the  point  of 


540        MISCELLANEOUS  LESIONS  AND  CONDITIONS  OF  COLON 

juncture,  the  sac  tends  to  fill  by  a  retrograde  movement  of  the 
ingested  meal,  which  may  remain  there  for  long  periods. 

Among  the  interesting  post-operative  cases  which  we  have 
examined  was  a  patient  who  had  a  five-year  history  of  abdominal 
discomfort  and  gas-distention.  Four  years  ago  her  appendix 
was  removed,  without  relief.  Sixteen  months  ago  an  ileo- 
sigmoidostomy  was  done,  but  the  results  were  disappointing. 
At  this  clinic  the  right  half  of  the  colon  was  resected  and  some 
improvement  in  the  patient's  condition  resulted,  but  she  still 
has  some  of  her  original  symptoms.  The  roentgenogram  (Fig. 
504)  shows  the  barium-filled  colon,  prior  to  the  last  operation. 
The  enema  divided  at  the  point  of  anastomosis ;  part  of  it  entering 
the  ileum,  the  loops  of  w^hich  can  be  seen,  and  the  other  stream 
passed  up  through  the  sigmoid  and  descending  colon.  The  two 
streams  met  at  the  hepatic  flexure. 

REFERENCES 

1.  DoERiNG,  H. :  "Die  Polyposis  intestini  und  ihre  Beziehung  zur 

carcinomatosen    Degeneration."     Arch.   f.    klin.    Chir.,    1907, 
Ixxxiii,  194-227. 

2.  SopER,  H.  W. :  "Polyposis  of  the  Colon."     Amer.  Jour.  Med.  Sci., 

1916,  di,  405-09. 

3.  CoNNELL,  F.  G. :  "Etiology  of  Lane's  Kink,  Jackson's  Membrane 

and  Cecum  Mobile."     Surg.,  Gynec.  &  Ohstet.,  1913,  xvi,  353- 
59. 

4.  Wilms:  "Das  Coecum  mobile  als  Ursache  mancher  Falle  von 

sogenannter  chronischer  Appendicitis."     Deutsch.  Med.  Wchn- 
schr.,  1908,  ii,  1756-58. 

5.  Case,  J.  T.:  "X-ray  Studies  of  the  Ileocecal  Region  and  the 

Appendix."     Am.  Quart.  Roentgenol.,  1912-13,  iv,  77-109. 

6.  Hahsmann,  T.  :  "Die  verschiedenen  Formen  des  Coecum  mobile." 

Mitt.  a.d.  Grenzgeb.  d.  Med.  u.  Chir.,  1913,  xxvi,  596-616. 

7.  Beclere    and    Meriel:  "L' exploration    radiologique    dans    les 

affections  chirurgicales  de  I'estomac  et  de  I'intestin."     Cong. 
Francais  de  Chir.,  1912,  xxv,  81. 

8.  ScHWARZ,  G. :  "The  Movable  Cecum:  Its  Demonstration  by  the 

Roentgen-rays."     Arch.  Diagnosis,  1910,  iii,  242-44. 

9.  Jackson,    J.   N.:  "Membranous   Pericolitis."     Surg.,   Gynec.    & 

Ohstet,  1909,  ix,  278-87. 


REFERENCES  541 

10.  Skinner,  E.  H.:  "The  Interpretation  of  Pericolic  Membranes."' 

Am.  Jour.  Roentgenol,  1913-14,  i,  474-86. 

11.  Lehmann,  C:  "Ein  Fall  von  Invaginatio  ileocoecalis  im  Rontgen- 

bilde."  Fortschr.  a.d.  Geb.  d.  Rontgenstrahlen,  1914,  xxi,  561- 
62. 

12.  Groedel,  F.  M.:  "Die  Invaginatio  ileocoecalis  im  Rontgenbild." 

Fortschr.  a.d.  Geb.  d.  Rontgenstrahlen,  1914-15,  xxii,  206-08. 

13.  Linde,  J.  I.  and  Kleiner,  S.  B.  :  "A  Case  of  Congenital  Idiopathic 

Dilatation  of  the  Colon  (Hirschsprung's  Disease)."  Arch. 
PediaL,  1915,  xxxii,  278-81. 

14.  Beclere  and  Mertel:  Loc.  cit.,  p.  91. 

15.  Case,  J.  T. :  "  Roentgenologic  Observations  on  the  Function  of  the 

Ileocolic  Valve."  Jour.  A.M. A.,  1914,  Ixiii,  1194-98.  "X- 
ray  Observations  on  Colonic  Peristalsis  and  Antiperistalsis, 
with  Special  Reference  to  the  Function  of  the  Ileocolic  Valve." 
Med.  Rec,  1914,  Ixxxv,  415-26. 

16.  DiETLEN,  H.:  "Die  Insuffizienz  der  Valvula  ileocoecalis  im  Ront- 

genbild." Fortschr.  a.d.  Geb.  d.  Rontgenstrahlen,  1914,  xxi,  23- 
30. 

17.  Groedel,  F.  M.:  "Die  Insuffizienz  der  Valvula  ileocoecalis  im 

Rontgenbild."  Fortschr.  a.d.  Geb.  der  Rontgenstrahlen,  1913, 
XX,  162-72. 

18.  Singer,  G.  and  Holzknecht,  G.:  "Ueber  objektive  Befunde  bei 

der  spastischen  Obstipation."  Miinch.  Med.  Wchnschr.,  1911. 
ii,  2537-39. 

19.  Keith,   A.:  Anatomical  Society  of  Great  Britain  and  Ireland, 

November,  1903,  7-20. 

20.  Rutherford,  A.  H. :  "The  Ileocecal  Valve."    New  York,  Hoeber, 

1914,  61. 

21.  Senn,    N.:  "Experimental    Surgery."     Chicago,    Keener,    1889, 

491. 

22.  Hertz,  A.  F. :  "Chronic  Intestinal  Stasis."     Brit.  Med.  Jour., 

1913,  i,  817-21. 

23.  Ppahler,  G.  E.  and  Stamm,  C.  J.:  "Diagnosis  of  Enteroliths  by 

Means  of  Rontgen-rays."  Surg.,  Gynec.  &  Obstet.,  1915,  xxi, 
14-17. 

24.  Case,   J.    T.:  "Roentgen   Studies   after   Gastric   and   Intestinal 

Operations."     Jour.  A.M.A.,  1915,  Ixv,  1628-34. 


BIBLIOGRAPHIC  INDEX 


Abbe,  468,  480 
Adami  and  NichoUs,  122,  151 
Alwens  and  Husler,  313,  317 
Andral,  220,  239 
Arnsperger,  302,  312 
Auerbach,  495 

Baetjer  and  Friedenwald,  113,  119 

Balfour,  327 

Balfour  and  Carman,  348 

Barclay,  50,  70,  74,   94,  111,    118,  119, 

137,  152,  294,  442,  449 
Barclay   and   Ramsbottom,    293,    294, 

311 
Barret  and  Leven,  317,  318 
Barsony,  328,  348 
Basch,  242,  249 
Bassler,  45,  73,  108,  109,  114,  119,  309, 

312,  494,  495,  506 
Beaumont,  106,  118 
Beck,  349,  372 
Becker,  302,  312 
Beckman,  533 
B^cl^re,  328,  378 
B^clere  and  Meriel,  309,  312,  378,  385, 

525,  530,  540,  541 
Bergeim,  Rehfuss  and  Hawk,  151,  152 
Bergmann  and  Lenz,  442 
Birch-Hirschfeld,  222,  239 
Blake  and  Cannon,  321 
Boas,  109 

Boas  and  Ewald,  108 
Bouchard,  493 
Brinton,  214,  218 
Brown,  488,  497,  506 
Brugel  and  Kaestle,  378 
Brugsch  and  Schneider,  220,  239 
Brunner,  223,  240,  481,  485 
Burchard,  292,  311 
Buttei-worth,  292,  311 


Cannon  and  Blake,  321 

Carman,  243,  327 

Carman  and  Balfour,  348 

Carman  and  Moore,  213 

Carman  and  Myer,  44,  73 

Case,  320,  321,  322,  347,  349,  350,  370, 

373,   447,  449,   497,   506,    508,    519, 

525,  530,  531,  537,  540,  541 
Chlumskij,  337,  348 
Christie,  222,  223,  240 
Clairmont  and  Haudek,  292,  311 
Clendening,  Outland  and  Skinner,  320, 

347 
Coffey,  498,  506 

Cohn,  325,  348,  508,  509,  512,  513,  519 
Cohnheim,  109 
Cole,  31,  33,  103,  113,  118,  119,  349,  350, 

373,  393,  428,  497,  506 
Cole  and  George,  373 
Combe,  493 

Connell,  521,  522,  523,  540 
Coolidge,  22 
Cornil,  222,  239 
Cronin,  220,  222,  239 
Crump,  45,  73 
Czerny,  337 

Daniel,  495,  506 

Dietlen,  509,  530,  531,  541 

Dodd  and  Harmer,  150,  152 

Doering,  520,  540 

Downes  and  LeWald,  221,  239 

Doyen,  337 

Dunn  and  Howell,  315,  318 

EiNHORN,  110,  119,  222,  239,  493,  494, 

505 
Ewald,  97,  108,  118,  148,  222 
Ewald  and  Boas,  108 
Ewald  and  Sievers,  108,  118 


Caldwell,  350,  373  Falconer,  299,  311 

CampbeU,  241,  249  Faroy,  222,  240 

Cannon,  91,    101,    105,    107,    118,    135,       Faulhaberm,  378,  385 

143,  151,  152,  309,  378,  385  Faulhaberm  and  Redwitz,  322,  347 

543 


544 


BIBLIOGRAPHIC   INDEX 


Fenwick,  220,  239 

Finney,  340 

Finsterer,  337,  348 

Flesch  and  Peteri,  313,  317 

Frank,  446 

Franke,  292,  311 

Friedenwald  and  Baetjer,  113,  119 

George,  349 

George  and  Cole,  373 

George  and  Gerber,  113,  114,  119,  508, 

509,  519 
George  and  Leonard,  350,  373 
Gerber  and  George,  113,  114,  119,  508, 

509,  519 
Glenard,  307,  493 
Graham,  172,  213 
Graham  and  Thompson,  218 
Graser,  467,  480 
Gray,  118 

Gray  and  Nesselrode,  241,  249 
Griffin,  301,  312,  467,  468,  480 
Griffin,  Mayo  and  Wilson,  467,  480 
Groedel,  102,   111,  112,  118,  119,    132, 

151,  308,  312,  508,  519,  529,  530,  541 

Haenisch,  436,  449 

Harmer  and  Dodd,  150,  152 

Hartel,  319,  320,  347 

Hartman,  Mikulicz  and  Polya,  343 

Haudek,  28,  30,  33,  81,  114,  115,  116, 

117,  120,  138,  139,  143,  147,  152,  252, 

266,  291 
Haudek  and  Clairmont,  292,  311 
Hausmann,  525,  540 
Hawk,    Rehfuss  and  Bergeim,  151,  152 
Hayes,  116,  120 
Heichelheim,  108,  118 
Heister,  438 

Hemeke  and  Mikulicz,  418 
Hemmeter,  250,  291 
Henselmann,  508,  519 
Hertz,    308,    312,    378,    385,    438,    443, 

446,  449,  450,  466,  494,  495,  497,  499, 

506,  508,  510,  519,  531,  541 
Hess  and  Hildebrand,  302,  312 
Hildebrand  and  Hess,  302,  312 
Hirsch,  41,  73 
Holding,  443,  449 
HoUtsch,  222,  240 
Holland,  293,  294,  311 


Holzknecht,  48,   74,  86,  90,   101,   103, 

117,  142,  144,  377,  440,  441,  449 
Holzknecht  and  Kaufman,  100,  118 
Holzknecht  and  Luger,  160,  170 
Holzknecht  and  Robinsohn,  138 
Holzknecht  and  Sgalitzer,  143,  152 
Holzknecht  and  Singer,  508,  518,  531, 

541 
Houston,  438 

Howell  and  Dunn,  315,  318 
Husler  and  Alwens,  313,  317 
Hiittenbach,  292,  295,  311 

Imboden,  508,  510,  519 

Jackson,  526,  527,  540 

Jaugeas,  371,  373 

Johnson,  316,  318 

Jonas,  138,  152 

Jordan,  440,   446,   447,   449,   496,   497, 

506 
Judd,  534 

Kaestle,  99,  102,  106,  112,  118,  119, 
134,  137,  151,  152,  308,  312 

Kaestle  and  Brugel,  378 

Kaestle,  Rieder  and  Rosenthal,  101, 
103,  118 

Kampmann,  292,  311 

Kaufman  and  Holzknecht,  100,  118 

Keith,  495,  496,  506,  531,  541 

Kemp,  108,  118 

Ivienbock,  302,  312 

Ivleiner  and  Linde,  529,  541 

Klemperer,  108,  119 

Koniger,  302,  312 

Ladd,  313,  318 
La  Fetra,  315,  318 
Lane,  307,  493,  494,  495,  496,  505 
Lehmann,  528,  541 
Lenz  and  Bergmann,  442 
Leonard  and  George,  350,  373 
Leube,  108 

Leube  and  Riegel,  108 
Leven  and  Barret,  317,  318 
LeWald,  315,  316,  318,  468,  480 
LeWald  and  Downes,  221,  239 
LeWald  and  Pisek,  314,  318 
LeWald  and  Satterlee,    112,    119,    143, 
152 


BIBLIOGRAPHIC    INDEX 


545 


LeWald  and  Smith,  317,  318 
Liertz,  508,  518 
Linde  and  Kleiner,  529,  541 
Lion  and  Moreau,  328,  348 
Lipsitz  and  Neilson,  143,  152 
Luger  and  Holzknecht,  160,  170 
Lyle,  215,  218 

Mathieu  and  Savignac,  327,  348 
Mayo  (C.  H.),  299,  311,  352,  373,  477 
Mayo  (W.  J.),  35,  201,  213,  327,  348, 

386,  389,  428,  471 
Mayo,  Wilson  and  Griffin,  467,  480 
Mayo-Robson,  327,  348 
McDowell  and  Wilson,  251,  291 
McGlannan,  215,  218 
McGrath,  467,  480 
McNeil,  221,  239 
M6riel  and  Beclere,  309,  312,  378,  385, 

525,  530,  540,  541 
Meyers,  222,  240 
MikuUcz,  457,  458,  472,  473,  474,  475, 

477 
Mikulicz,  Hartman  and  Polya,  343 
Mikulicz  and  Hemeke,  418 
Mills,  222,  223,  240 
Mixter,  498,  506 
Moore,  292,  311 
Moore  and  Carman,  213 
Moreau  and  Lion,  328,  348 
Morgan,  222,  223,  240 
Moynihan,  336,  337,  348,  496,  506 
Moynihan  and  Tatlow,  327,  328,  348 
Muhlmann,  222,  223,  240 
Myer,  118,  220,  222,  239,  242,  244,  249 
Myer  and  Carman,  44,  73 

Nassetti,  241,  249 
Neilson  and  Lipsitz,  143,  152 
Nesselrode  and  Gray,  241,  249 
Neumann,  220,  239 
Nicholls  and  Adami,  122,  151 

OuTLAND,     Skinner    and     Clendening, 
320,  347 

Paterson,  326,  348 

Peteri  and  Flesch,  313,  317 

Petit,  33 

Pfahler,  349,  372,  497,  506 

Pfahler  and  Stamm,  534,  541 


Pisek  and  LeWald,  314,  318 
Plummer,  33 

Polya,  Mikulicz  and  Hartman,  343 
Portis,  30,  33 

Ramsbottom  and  Barclay,  293,  294,  311 

Redwitz  and  Faulhaberm,  322,  347 

Rehfuss,  Bergeim  and  Hawk,  151,  152 

Reiche,  250,  252,  291 

Reuben,  315,  318 

Rhein  and  Sailer,  302,  312 

Richter,  315,  318 

Rieder,    111,    112,    113,    115,    119,   250, 

441,  508,  509,  519 
Rieder,    Kaestle   and   Rosenthal,    101, 

103,  118 
Rieder  and  Rosenthal,   102,    118,   119, 

151,  312,  385 
Riegel,  108,  109,  113,  114,  148 
Riegel  and  Leube,   108 
Robinsohn  and  Holzknecht,  138 
Robson,  327,  348 

Rosenthal,  Kaestle,  Rieder,  101, 103, 118 
Rosenthal  and   Rieder,    102,    118,    119, 

151,  312,  385 
Rowden,  328 
Rubaschow,  350,  372 
Rudniew,  220 
Rutherford,  531,  541 
Ruysch,  241 

Sahli,  143 

Sailer  and  Rhein,  302,  312 

Salomon,  139 

Satterlee  and  LeWald,    112,    119,    143, 

152 
Savignac  and  Mathieu,  327,  348 
Schlesinger,  92,  93,  94,  118,   131,  151, 

309,  312 
Schneider  and  Brugsch,  220,  239 
Schwarz,  100,  118,  292,  311,  441,  447, 

449,  486,  487,  492,  500,  507,  526,  540 
Selby,  525 
Senn,  531,  541 
Sever,  314,  318 

Sgalitzer  and  Holzknecht,  143,  152 
Sherren,  241,  249 
Sievers  and  Ewald,  108,  118 
Singer  and  Holzknecht,  508,  518,  531, 

541 
Skinner,  500,  507,  527,  541 


546 


BIBLIOGRAPHIC   INDEX 


Skinner,  Outland  and  Clendening,  320,       Thompson  and  Graham,  218 


347 
Smith  and  LeWald,  317,  318 
Soper,  520,  540 
Soresi,  327,  348 
Stamm  and  Pfahler,  534,  541 
Stendel,  337 
Stewart,  73,  74 

Stiller,  82,  83,  86,  95,  117,  310,  312 
Stockton,  309,  312 
Sullivan,  369 


Treitz,  377 

Tuohy,  220,  229,  239 

ViRCHOw,  467 


Wade,  241,  249 

Willox,  314,  318 

Wilms,  413,  446,  524,  526,  540 

Wilson,  468,  480 

Wilson,  Mayo  and  Griffin,  467,  480 

Wilson  and  McDowell,  251,  291 

Tatlow  and  Moynihan,  327,  328,  348      Wolfler,  337 

Thompson,  214  Wulach,  111 


INDEX  OF  SUBJECTS 


Abdominal  wall,  relation  of,  to  normal 

stomach,  86 
Abscess,  fistulous  appendiceal,  517 

retrocecal,  517 

subdiaphragmatic,  appearance,  371 
Adenoma,  papillary,  of  stomach,  242 
Aerophagy  in  infancy,  317 
Air  as  medium,  26 
Anesthesia,   general,    effect   on   gastro- 

spasm,  166 
Antiperistalsis    in    abnormal    stomach, 
138 

in  gastric  cancer,  189 
ulcer,  267 

in  normal  colon,  441 
Antrum  cardiacum,  79 

pylori,  80 
Apoplectic  habitus,  83 
Apparatus,  roentgen-ray,  17 
Appendicitis,  chronic,  508 
enterospasm  from,  510 
position  of  appendix  in,  510 
roentgenologic  signs,  509,  511 
Appendix,  fistulous  abscess  of,  517 

mobility  of,  509 

position  of,  in  chronic  appendicitis, 
510 

technic  of  examination,  510 
Asthenia  universalis  congenita,  82 
Atonic  stomach,  94 
Atropin  sulphate  test  for  indirect  gas- 

trospasm,  164 
Auto-intoxication     from     chronic     in- 
testinal stasis,  symptoms,  494 

Barium  cornstarch  pap  as  medium,  76 

sulphate  as  medium,  25,  75 
Barium-acacia  mixture  as  medium,  41 
Bariumized  gruel  as  medium,  42 
Bassler's  mixed-meal  method  of  testing 

gastric  motility,  114 
Bauhin's  valve,  insufficiency  of,  530 
Belladonna  test  for  indirect  gastrospasm, 
164 


Benign    tumors    of   stomach,    case    re- 
ports, 245-249 
Bile,  effect  of,   on  appearance  of  gall- 
stones, 352 
Bismuth  oxychlorid  as  medium,  25 
subcarbonate  as  medium,  25 
subnitrate  as  medium,  25 
Bismuth-acacia  mixture  as  medium,  41 
Blood-changes    from   roentgen   ray,  30 
Boas  and  Ew aid's  test-breakfast,  108 
Boas  test  for  pyloric  stenosis.  109 

Calculi,      renal,      demonstrated     by 
pyelogram,  357,  358 
gall-stones  and,   differentiation  of 
shadows  from,  357 
Cancer  of  colon,  450 

case-reports,  455-466 
demonstration  of  signs  of,  450 
filling-defects  in,  450 

conditions  simulating,  451 
from  adhesions,  454 
from  diverticulitis,  455 
from  extrinsic  tumors,  454 
from  gas  collections,  451 
from  insufficient  enema,  452 
from  localized  spasm,  452 
from  pressure  of  spine,  454 
interpretation,  455 
obstruction  in,  450 
of  stomach.     See  Gastric  cancer. 
Carcinomatous  gastric  ulcer,  269 

roentgen  characteristics,  196 
Cardiospasm,  case  reports,  58-62 
demonstration  of,  method,  44 

with  sausage-skins,  45 
differential  diagnosis,  51 
roentgen-ray  characteristics,  50 
Case  observations,  records  of,  32 
Cecum,  fixation  of,  523 
migration  of,  522 
incomplete,  524 
mobile,  524 

et  atonicum,  446 


[547 


548 


INDEX    OF    SUBJECTS 


Cecum,  rotation  of,  522 

Children,  stomach  in.     See  Stomach  in 

infancy. 
Cholecystitis,  Riedel's  lobe  in,  370 
Cholesterin  gall-stones,  appearance,  352 
Cicatricial  stricture  of  esophagus,  cases, 
68-70 
observation  of,  65 
Cirrhosis  of  stomach,  214 
case  reports,  217 
characteristics,  214 
clinical  summary,  215 
roentgenologic  manifestations,  215 
Coil,  roentgen-ray,  17 
Cole's  gastric  cycles,  103 
Colitis,  chronic,  486 

case  reports,  487-492 
Colon,  abnormal,  443 
peristalsis  in,  447 
variations  of  position,  443 
adhesions  of,  447 

after  operation,  roentgenology  of,  537 
anomalies  of  migration  and  rotation, 

521 
cancer  of.     See  Cancer  of  colon. 
causes  of  displacement  of,  445 
congenital    idiopathic    dilatation    of, 

529 
dilatation,  448 
diminished  mobility  of,  446 
filhng-defects  in,  causes,  446 
gas  in,    simulating   filling-defects  in 

gastric  cancer,  180 
hypermotility  of,  448 

constipation  from,  500 
hyperperistalsis  in,  447 
hypomotility,  448 
increased  mobility  of,  446 
intussusception  of,  528 
irregularities  of  contour,  446 
miscellaneous  lesions  of,  520 
narrow,  448 
non-rotation  of,  445 
normal,  436 

antiperistalsis  in,  441 

capacity,  439 

haustral  segmentation  in,  441 

mobility,  440 

motility,  442 

peristalsis  in,  440 

position,  437 


Colon,  normal,  variations  in  contour,  438 
in  position,  437 

peristalsis  in,  exaggerated,  447 

polyposis  of,  520 

ptosis  of,  445 

redundant,  448 

situs  transversus  of,  443 

transposition  of,  527 

tuberculosis  of,  481 
case  reports,  481-485 
Constipation,  493 

adhesions  in,  501 

atonic  type,  501 

cecal  type,  501 

from  hypermotility  of  colon,  500 

Hertz's  classification,  499,  500 
definition,  490 

hypertonic,  502 

rectal  type,  501 

Skinner's  types  of,  500 

spastic,  502 
Coolidge  roentgen-ray  tube,  22 
Cornstarch   pap,    as   vehicle,    prepara- 
tion of,  27 
Cysts,  dermoid,  of  stomach,  241 

of  liver,  hydatid,  appearance,  37 1 

Dermoid  cyst  of  stomach,  241 
Developers,  roentgen-ray,  22 
Diaphragm,  elevation  of,  302 
Diaphragmatic  hernia,  301 
case  report,  304-307 
paradoxic  respiratory  phenomenon 
in,  304 
Dilatation  of    colon,     congenital    idio- 
pathic, 529 
of  esophagus,  observation,  50 
of  ileum,  383 
Diverticula,  false,  467 
of  duodenum,  381 
of  stomach,  297 
case-report,  301 
Diverticulitis,  467 
case  reports,  469-477 
differential  diagnosis,  468 
in  cancer  of  colon,  filling  defects  from, 

455 
pathology,  467 
shadows  in,  477 

shadows  in,  conditions  imitating,  478 
haustral,  478 


INDEX    OF    SUBJECTS 


549 


Diverticulitis,  shadows  in,  rounded,  477 

symptomatolog}',  4G8 
Diverticulum  of  esophagus,  cases,  63-65 
classification,  62 
observation  of,  62 
Duodenal,     contour,    irregularities     of, 

causes,  380 
Duodenal  xilcer,  386 
adhesions  with,  390 
alterations  of    gastric  motility  in, 
406 
of  gastric  tone  in,  403 
association  ■with  gastric  ulcer,  268 
bulbar  deformity  in,  396 

accessory  pocket  in,  397 
at  basal  border,  395 
diverticulum  in,  399 
niche-tj'pe,  396 
smaU,  397 

with  general  distortion,  393 
incisura  type,  397 
significance,  399 
callous,  388 
case  reports,  412 
common  location,  388 
concurrence  with  gastric  ulcer,  412 
deformity  of  duodenal  contour  in, 

392 
gastric  hypermotility  in,  406 
hyperperistalsis  in,  405 
hypertonus  in,  403 
hypotonus  in,  403 
peristalsis  in,  405 
gastrospasm  in,  408 
hunger-pains  of,  386 
incisura  in,  408 
kissing,  388 

macroscopic  appearance,  388 
old,  389 

pathologic  anatomy,  387 
patholog}',  387 
perforating,  390 
roentgenologic  signs,  392 
direct,  392 
indirect,  403 
value,  411 
scarring  in,  388 
sjTnptom-complex,  386 
technic  of  roentgenologic  examina- 
tion. 390 
tenderness  in.  411 


Duodenum,  abnormal,  380 
delayed  motility  in,  382 
diverticula  of,  381 
evidences  of  obstruction  in,  381 
hyperperistalsis  of,  382 
lessened  mobility  of,  382 
normal,  374 

anatomic  divisions,  374 

descending  portion,  376 

pars  superior  of,  374 

peristaLsis  in,  377 

transverse  portion,  377 
Dj'schezia,  500 

ExEMA,  opaque,  27 

medixims  for,  27 
Enterohths,  533 
Enteroptotic  habitus,  82 
Enterospasm  from  chronic  appendicitis, 

510 
Enterostomy,  stomach  after,  320 
Epicardia,  examination  of,  position  of 

patient,  43 
Esophagus,  anatomic  memoranda,  46 
cicatricial  strictures  of,  cases,  68-70 

observation,  65 
deformitj-  of  contour,  observation  of, 

48 
dilatation  of,  observation,  50 
displacement,  causes,  48 
diverticulum  of,  cases,  63-65 
classification,  62 
observation  of,  62 
examination  of,  supplementary  stom- 
ach examination  with,  45 
fistula  of,  71 

foreign  bodies  in,  locahzation  of,  71 
interpretation  of  findings  in,  46 
miscellaneous  lesions  of,  71 
movements,  47 
normal,  appearance,  47 
obser\^ation  of  peristalsis  in,  47 

of  obstruction  in,  49 
paralysis  of,  71 
pathologic  appearance,  48 
piles  of,  73 
polyps  in,  73 
roentgenographj-  of,  44 
media,  44 

position  of  patient,  42,  43,  44 
variations  in  technic,  44 


550 


INDEX    OF    SUBJECTS 


Esophagus,  roentgenoscopy  of,  39 
barium-acacia  mixture  for,  41 
bariumized  gruel  in,  42 
bisniuth-acacia  in,  41 
position  of  patient,  39,  40 
technic,  39 
spasm  of,  70 

Eventration,  302 

Ewald  and  Boas'  test-breakfast,  108 

Ewald's  test-meal,  108 

Fibromatosis  of  stomach,  214 
case  reports,  217 
characteristics,  214 
clinical  summary,  215 
roentgenologic  manifestations,  215 
Fibrosis  of  stomach,  214 
case  reports,  217 
characteristics,  214 
clinical  summary,  215 
roentgenologic  manifestations,  215 
Filling-defects  in  abnormal  stomach,  126 
in  cancer  of  colon,  450 

conditions  simulating,  451 
in  gastric  cancer,  173 
at  pars  media,  178 

pylorica,  178 
determining  permanence,  176 
food  masses  simulating,  180 
from  faulty  media,  179 
gas  in  colon  simulating,  180 
hair-ball  simulating,  180 
imprisoned  secretion  simulating, 

180 
perigastric  adhesions  simulating, 

184 
retraction  of  belly-wall  simulat- 
ing, 181 
spasm    of    gastric    musculature 

simulating,  183 
spinal     deformities     simulating, 

181 
true  and  simulated,  differentia- 
tion, 184 
variations,  175 
in  stomach  from  causes  other  than 
cancer,  179 
from  extrinsic  tumors,  185 
from  pressure  against  spine,  181 
spastic,  antispasmodic    treatment, 
184 


Fish-hook  stomach,  79,  87 

acute,  in  gastric  ulcer,  266 
Fistulse,  intestinal,  534 

of  esophagus,  71 
Fixation  of  cecum,  523 
Fluoroscopy.     See  also  Roentgenoscopy. 
Food  masses  simulating  filling-defects 

in  gastric  cancer,  180 
Foot-switch  for  roentgenoscopy,  19 
Foreign  bodies  in  esophagus,  localiza- 
tion of,  71 
in  stomach,  297 
intestinal,  534 
Fornix  of  stomach,  79 
Fundus  of  stomach,  79 

Gall-bladder  diseases,  363 

gastric  disorders  simulating,  370 
symptoms  in,  367 

gastrospasm  in,  159,  367 

hyperperistalsis  in,  370 

indirect  signs  in,  363 

relation  of  gastric  disorders  to, "367 

six-hour  residue  in,  367 
gall-stones  in,  appearance,  352 
Gall-stones,  calcified  lymph-nodes  and, 

differentiation,  357 
case  reports,  360-363 
cholesterin,   appearance,   352 
effect  of  lime  salts  on  appearance,  352 

of  liver-tissue  on  appearance,  353 
factors  affecting  demonstrability,  352 
faults  in  roentgenology  of,  351 
in  gall-bladder,  appearance,  352 
mixed  type,  appearance,  352 
percentage  of  incidence,  352 
position  of  shadows  from,  356 
renal   calculi  and,   differentiation  of 

shadows  from,  357 
roentgenology  in,  349 
sources  of  error  in  demonstration,  360 
technic  of  demonstration,  355 
Gas  as  medium,  26 

in  colon  simulating  filling-defects  in 

gastric  cancer,  180 
Gas-bubble  in  abnormal  stomach,   133 

in  normal  stomach,  99 
Gastric  cancer,  171 

absence  of  peristalsis  in,  189 

alteration  of  pyloric  function  in, 
186 


INDEX    OF   SUBJECTS 


551 


Gastric  cancer,  altered  capacity  of  stom- 
ach in,  191 

motilitj'  of  stomach  in,  189 

size  of  stomach  in,  191 
antiperistalsis  in,  189 
broad  incisura  of,  191 
case  reports,  205-213 
clinical  data  in,  172 
colloid,  194 
degenerative,  194 
diagnosis,  171 

early,  203 
diffuse,  214 

displacement  of  stomach  in,  191 
early,  202 

evidences  of  inoperability  in,  201 
exaggerated  peristalsis  in,    189 
filling-defects  in,  173 

at  pars  media,  178 
pylorica,  178 

determining  permanence,  176 

food  masses  simulating,  180 

gas  in  colon  simulating,  180 

hair-ball  simulating,  180 

imprisoned  secretion  simulating, 
180 

perigastric  adhesions  simulating, 
184 

retraction  of  belly-wall  simulat- 
ing, 181 

spasm    of    gastric    musculature 
simulating,  183 

spinal     deformities     simulating, 
181 

true  and  simulated,  differentia- 
tion, 184 

variations,  175 
forms,  192 
fungous,  192 

characteristic  appearance,  194 
gaping  of  pylorus  in,  186 
gastriculcer  and,  differentiation,  268 
gastrospasm  in,  157 

persistent  local,  191 
hour-glass  stomach  in,  179 
hypermotility  in,  189 
hypomotility  in,  190 
infiltrative,  192 
latent,  202 

lessened    flexibility  of  stomach  in, 
190 


Gastric    cancer,    lessened    motility    of 
stomach  in,  190 

metastasis,  roentgen  diagnosis,  201 

mucoid,  194 

roentgen  characteristics,   196 

operability,  198 

pathology,  192 

perversions  of  peristalsis  in,  189 

proliferative,  192 

pyloric  obstruction  in,  188 

roentgenologic  manifestations,  172 

scirrhous,  192 

roentgen  characteristics,  194 

syphilis  of  stomach  and,  differentia- 
tion, 224 

weak  peristalsis  in,  189 
cycles  of  Cole,  103 

disorders,  relation  of,  to  gall-bladder 
diseases,  367 

simulating    gall-bladder    diseases, 
370 
hypermotiUty  in  duodenal  ulcer,  406 
hyperperistalsis  in  duodenal  ulcer,  405 
hypertonus  in  duodenal  ulcer,  403 
hypotonus  in  duodenal  ulcer,  403 
motility,  alterations   of,  in  duodenal 

ulcer,  406 
neoplasms,  benign,  172 
peristalsis,  alterations  of,  in  duodenal 

ulcer,  405 
retention  in  pyloric  ulcer,  156 
syphilis,  219 
ulcer,  250 

abnormalities  of  peristalsis  in,  266 

accessory  pocket  in,  256 

acute  fish-hook  stomach  in,  266 

adhesion-band  in,  259 

antiperistalsis  in,  267 

association    with    duodenal    ulcer, 
268 

carcinomatous,  252,  269 

case  reports,  271-291 

classes  of,  251 

concurrence  with  duodenal  ulcer, 
412 

contributory  signs,  257 

diagnosis,  250 

differentiation  of  gastrospasm  in, 
261 

diffuse  gastrospasm  in,  156 

forms  of  gastrospasm  in,  261 


552 


INDEX    OF    SUBJECTS 


Gastric  ulcer,  gastric  cancer  and,  differ- 
entiation, 268 
gastrospasm  from,  forms,  154 
hour-glass  stomach  in,  organic,  263 
hj-potonus  in,  264,  267 
incisura  in,  257-261 
lessened  mobiUt}'  in,  267 
niche  in,  252 
penetrating,  251 

niche  of,  124,  125 
perforating,  251 

accessor}-  pocket,  124 
residue  in  stomach  in,  264 
roentgenologic  signs,  252 
shallow,  251 

spasmodic  hour-glass  stomach  in, 
261 
manifestations,  257 
syphihtic,  220 
annular,  221 
tender  point  in,  267 
value  of  sign-groups  in,  268 
Gastritis,  syphilitic,  220 
Gastro-enterostomy,  regurgitant  vomit- 
ing after,  case  reports,  338-341 
causes,  337 
roentgenology-  in,  336 
stomach  after,  classes,  320 

roentgenology  of,  320 
"s-icious  circle  after,  case  reports,  33S- 
341 
causes,  336 
Gastro-intestinal  tract,  roentgenoscopy 

of,  29 
Gastrojejiinal  lolcer,  postoperative,  326 
case  reports,  331-336 
etiology,  327 
grouping  of  roentgen  phenomena 

in,  331 
lessened  mobility  of  stomach  in, 

330 
obstructive  sj-mptoms  in,  330 
six-hour  retention  in,  330 
S3-mptoms,  327 
Gastrojejunostomy,      stomach      after, 

roentgenology  of,  321 
Gastropex3',    stomach    after    roentgen- 
ology of,  325 
Gastroptosis,  307-311 
clinical  conception,  308 
status  of,  309 


Gastroptosis,    pyloroptosis   as   sign   of 

132 
Gastrospasm,  153 
case  reports,  168-170 
differentiation,  162 

in  gastric  ulcer,  261 
diffuse,  in  gastric  ulcer,  156 
effect  of  general  anesthesia  on,  166 
etiolog}',  162 
extrinsic,  158 

forms  of,  in  gastric  ulcer,  261 
from  deformity  of  gastric  outhne,  163 
from  disease  conditions,  163 
from  gastric  ulcer,  forms,  154 
hour-glass  stomach  in,  154 
in  cancer  of  stomach,  157 
in  duodenal  ulcer,  408 
in  gaU-bladder  disease,  159,  367 
in  pyloric  ulcer,  156 
incisura  in,  154 
indirect,  atropin  sulphate  test  for,  164 

belladonna  test  for,  164 

causes,  164 
intrinsic,  158 
manifestations,  162 
persistent  local,  in  gastric  cancer,  191 
total,  160 
types,  154 
with  incisura,  154 
Gastrostomy,     stomach     after,     roent- 
genology of,  325 

Habitus,  apoplectic,  83 
broad,  83 
enteroptotic,  82 
normal,  S3 

relation  of,  to  position  of  stomach, 
82-86 
Hair-ball  of  stomach,  292 
case-reports,  296,  297 
etiology,  294 
symptoms,  295 
simulating    filHng-defect    in    gastric 
cancer,  180 
Haudek's  double-meal  method  of  test- 
ing gastric  motility,  114 
hubhohe,  81 
Haustral  segmentation  in  normal  colon, 

441 
Hernia,  diaphragmatic,  301 
case  report,  304-307 


INDEX    OF    SUBJECTS 


553 


Hernia,    diaphragmatic,    paradoxic    re- 
spiratory phenomenon  in,  304 
mucosae  of  stomach,  299 
Hertz's    classification    of    constipation, 
499,  500 
definition  of  constipation,  490 
Hirschsprung's  disease,  529 
Hour-glass  stomach,  121 
causes,  122 
congenital,  122 
gastrospasm  in,  154 
in  gastric  cancer,  179 
organic,  in  gastric  ulcer,  263 
simulation  of,  124 
spasmodic,  in  gastric  ulcer,  261 
varieties,  122,  123 
Hubhohe,  Haudek's,  81 
Hunger-pains  of  duodenal  ulcer,  386 
Hydatid  cysts  of  liver,  appearance,  371 
Hypermotility,     gastric,     in    duodenal 
ulcer,  406 
in  abnormal  stomach,  139 
in  gastric  cancer,  189 
of  colon,  448 

constipation  from,  500 
zone  of,  in  abnormal  stomach,  148 
Hyperperistalsis  in  abnormal  stomach, 
135 
in  colon,  447 
in  duodenum,  382 
in  gall-bladder  diseases,  370 
Hypertonic  stomach,  92 

in  duodenal  ulcer,  403 
Hypomotility  in  abnormal  stomach,  143 
in  colon,  448 
in  gastric  cancer,  190 
zone  of,  in  abnormal  stomach,  148 
Hypotonic  stomach,  93 

in  duodenal  ulcer,  403 
Hypotonus  in  gastric  ulcer,  264,  267 

Ileocecal  valve,  incompetence  of,  530 
Ileum,  abnormal,  383 

dilatation  of,  383 

immobility  of,  384 

kinks  of,  384 

normal,  379 

peristalsis  in,  380 
terminal  segment,  379 

obstruction  in,  causes,  384 

ptosis  of,  383 


Incisura  angularis,  79 

broad,  of  gastric  cancer,  191 
cardiaca,  79 
gastrospasm  with,  154 
in  duodenal  ulcer,  408 
in  gastric-ulcer,  257-261 
Infants,  stomach  in.     See  Stomach  in 

infancy. 
Intensifying     screens     for     roentgen- 
ography, 22 
Interrupter,  roentgen-ray,  17 
Interrupterless    transformer,    roentgen- 
ray,  18 
Intestine,  fistulse  of,  534 
foreign  bodies  in,  534 
large,  technic  of  roentgenologic  ex- 
amination, 434-436 
small,  374 

abnormal,  380 
miscellaneous  lesions  of,  429 

case  reports,  429-433 
normal,  374 
motility,  380 

time  for  complete  evacuation,  380 
Intussusception  of  colon,  528 
Iron,  magnetic  oxide,  as  medium,  25 

Jackson's  membrane,  526 
Jejunal  ulcer,  postoperative,  326.     See 
also  Gastrojejunal  ulcer,  'postoperative. 
Jejunum,  abnormal,  382 
normal,  377 

course  of  first  segment,  377 
pendulum  movements  in,  378 
peristalsis  in,  378 
rhythmic  segmentation  in,  378 
obstruction  in,  causes,  382,  383 

Keith's  nodal  tissue,  495 
Kinematography,  roentgen,  32 
Kinks,  Lane's,  494 
Kontrastin  as  medium,  25 

Lane's  definition  of  chronic  intestinal 

stasis,  493 
kinks,  494 

points  of  occurrence,  494 
Leather-bottle  stomach,  13S,  214 

case  reports,  217 

characteristics,  214 

clinical  summary,  215 

roentgenologic  manifestations,  215 


554 


INDEX    OF    SUBJECTS 


Leube-Riegel  test-dinner,  108 
Leube's  test-meal,  108 
Linitis  plastica,  214 
case  reports,  217 
characteristics,  214 
clinical  summary,  215 
roentgenologic  manifestations,  215 
Liver,  370 

cancer  of,  appearance,  371 
displacement,  causes,  371 
examination  of,  370 
hydatid  cysts  of,  appearance,  371 
increase  of  volume,  causes,  370 
local  deformities,  370 
roentgenology  of,  370 
Liver-tissue,  effect  of,  on  appearance  of 

gall-stones,  353 
Lymph-nodes,  calcified  gall-stones  and, 
differentiation,  357 

Magenblase,  79 
Mediums  for  visualization,  25 
Megacolon,  529 
Megasigmoid,  529 
Membrane,  Jackson's,  526 
Migration  of  cecum,  522 

incomplete,  524 
Mobility,  lessened,  in  gastric  ulcer,  267 

Niche  in  gastric  ulcer,  252 
Nodal  tissue,  Keith's,  495  ^k 

Obstipation,  chronic,  dyskinetic,  500 

hypokinetic,  500 
Opaque  enema,  27 
mediums  for,  27 
meal,    Rieder's    for    testing    gastric 

motility.  111 
salts  as  media,  25 

quantities  used,  28 
for  tests  of  gastric  motility,  110 
Operator,  protective  measures  for,  30 
Orthotonic  stomach,  92 
Oxide  of  iron,  magnetic,  as  medium,  25 
of  thorium  as  medium,  25 
of  zirconium  as  medium,  25 
Oxychlorid  of  bismuth  as  medium,  25 

Palpation  before  roentgenoscopy,  30 
Papillary  adenoma  of  stomach,  242 
Paralysis  of  esophagus,  71 
Pars  cardiaca,  79 


Pars  intermedia,  79 
media,  79 

filling-defects  at,  in  gastric  cancer, 
178 
pylorica,  80 

filling-defects  at,  in  gastric  cancer, 
178 
Patient,  preparation  of,  24,  30 

for  examination  of  stomach,  75 
protective  measures  for,  31 
Pendulum  movements  in  normal  jeju- 
num, 378 
Peridiverticulitis,  467 
Perigastric  adhesions  simulating  filling- 
defects  in  gastric  cancer,  184 
Peristalsis,  abnormahties  of,  in  gastric 
ulcer,  266 
absent,  in  gastric  cancer,  189 
exaggerated,  in  gastric  cancer,  189 
in  abnormal  stomach,  134 

absence  of,  135 
in  colon,  exaggerated,  447 
in  duodenal  ulcer,  403 
in  normal  colon,  440 
duodenum,  377 
ileum,  380 
jejunum,  378 
stomach,  100 
delayed,  105 
varieties,  102 
lack  of,  in  infancy,  313 
of  esophagus,  observation  of,  47 
perversions  of,  in  gastric  cancer,  189 
weak,  in  gastric  cancer,  189 
Permanent  record,  33 
Piles,  esophageal,  73 
Plates,  roentgen-ray,  22 
Pocket,  accessory,  in  gastric  ulcer,  256 

in  stomach,  299 
Polyposis  of  colon,  520 
of  esophagus,  73 
of  stomach,  241,  243 
Preparation  of  patients,  30 

for  examination  of  stomach,  75 
Protective  measures  for  operator,  30 

for  patient,  31 
Ptosis  of  colon,  445 

of  ileum,  383 
Pyloric  ring,  80 
ulcer,  gastric  retention  in,  156 
gastrospasm  in,  156 


INDEX    OF    SUBJECTS 


555 


Pyloroplasty,  stomach  after,  roentgen- 
ology of,  321,  325 
Pyloroptosis  as  sign  of  gastroptosis,  132 
Pylorospasm,  gastric  retention  from,  142 
Pylorus  after  operation,  roentgenology 
of,  321 
alteration  of  function,  in  gastric  can- 
cer, 186 
congenital  stenosis  in  infancy,  315 
gaping,  in  gastric  cancer,  186 
obstruction  at,  in  gastric  cancer,  188 
positions  of,  in  abnormal  stomach,  131 
stenosis  of,  Boas'  test  for,  109 

Radiography,  serial,  31 
Recapitulation  records,  33 
Records  of  case  observations,  32 
permanent,  33 
recapitulation,  33 
Rectum,  roentgenology  of,  537 
References  to  literature,   33,    73,    117, 
151,  213,  218,  239,  291,  311,  317,  347, 
373,  385,  428,  449,  480,  485,  492,  505, 
518,  540 
Retrocecal  abscess,  517 
Rhythmic  segmentation  in  normal  jeju- 
num, 378 
Riedel's  lobe  in  cholecj^stitis,  370 
Rieder's  opaque  meal  for  testing  gastric 

motility,  111 
Riegel  test-dinner,  108 
Ring,  pyloric,  80 
Roentgen  ray,  kinematography,  32 

and  stomach  tube  findings  in  gastric 

motility,  comparison,  148 
apparatus,  17 
blood-changes  from,  30 
coil,  17 

developers,  22 
interrupter,  17 
plates,  22 
steriUty  from,  30 
table,  20 
transformer,  18 

interrupterless,  17,  18 
tubes,  21 
Coolidge,  22 
Roentgenogram,  exposure  necessary  for, 

23 
Roentgenography,    diagnosis   by,    haz- 
ards of,  36 


Roentgenography,   intensifying  screens 
for,  22 

when  preferable,  31 

diagnosis  by,  essentials  for,  38 

differential  diagnosis  in,  35 

findings  by,  correlation  with  clinical 
findings,  37 

interpretation  of  findings  in,  34 

re-examination  in,  35 
Roentgenoscopy,  foot  switch  for,  19 

of  gastro-intestinal  tract,  29 

palpation  before,  30 

preparation  of   observer's   eyes   for, 
29 

protective  measures  for  operator,  30 

room-light  for,  30 

tube  stand  for,  20 

vertical  screen  apparatus  for,  18 

when  preferable,  31 
Room-light  for  roentgenoscopy,  30 
Rotation  of  cecum,  522 

Sahli's     capsules     for    differentiating 
causes  of  gastric  retention,  143 
opaque     capsules     for     determining 
secretion  in  fasting  stomach,  99 
Salts,  opaque,  as  media,  25 
Sausage-skins  for  demonstrating  cardio- 
spasm, 45 
Schlesinger's   classification  of  stomach 

tonus,  92 
Schwarz's     fibrodermic     capsules     for 
determining  digestive  power  of  stom- 
ach, 100 
Screen  apparatus,   vertical,   for  roent- 
genoscopy, 18 
examination.     See  Roentgenoscopy. 
intensifying,  for  roentgenography,  22 
Serial  radiography,  31 
Six-hour  meal  for  visualization,  28 
advantages,  29 
in  examination  of  stomach,  75 
zones  of  motility  based  on,  in  ab- 
normal stomach,  146 
Skinner's  types  of  constipation,  500 
Spasm  of  esophagus,  70 
Spasmodic  hour-glass  stomach  in  gas- 
tric ulcer,  261 
Spinal    deformities    simulating    filling- 
defects  in  gastric  cancer,  181 
Stasis,  chronic  intestinal,  493 


556 


INDEX    OF    SUBJECTS 


Stasis,  chronic  intestinal,  auto-intoxica- 
tion from,  symptoms,  494 
Lane's  definition,  493 
roentgenologic  signs  in,  496 
Steer-horn  stomach,  79,  87 
Stenosis  of  pylorus,    congenital,  in  in- 
fancy, 315 
Sterility  from  roentgen-ray,  30 
Stomach,  abnormal    121 

absence  of  peristalsis  in,  135 
alterations  in  size,  132 

of  tone,  129 
altered  mobility,  132 

position,  131 
antiperistalsis  in,  138 
causes  of  retention  in,  142 
changes  of  contour,  124 
disordered  motOitj'-  in,  139 
filling-defects  in,  126 
gas-bubble  in,  133 
gastrospasm  from,  163 
hypermotility  in,  139 
hyperperistalsis  in,  135 
hypertonic,  129 
hypomotihtj^  in,  143 
hypotonic,  131 
incisura  in,  126,  129 
lessened  flexibility  of,  133 
motUitj',  comparison  of  roentgenray 
and  stomach  tube  findings,  148 
six-hour  meal  test  for,  148 
motor-meal  in,  140 
peristalsis  in,  134 
positions  of  pylorus  in,  131 
retention  in,  141 

double-meal  method  in,  144 
from  pylorospasm,  142 
incidence,  150 
Sahh's    capsules    for    determining 

cause  of  retention  in,  143 
secretion  in,  134 
significance  of  retention  in,  145 
six-hour  residue  in,  141 
variations  in  form,  121 
zone  of  hypermotUity  in,  148 

of  hypomotility  in,  148 
zones  of  motility  based  on  six-hour 
meal,  146 
accessory  pocket  in,  299 
after  enterostomj^,  roentgenology  of, 
319 


Stomach       after      gastro-enterostomj^, 
classes,  320 
roentgenology  of,  320 
after    gastrojejunostomy,    roentgen- 
ology of,  321 
after  gastropexy,  roentgenology  of,  325 
after  gastrostomy^,  roentgenology  of, 

325 
after  operation,  roentgenology  of,  319 
after  pyloroplasty,  roentgenology  of, 

321,  325 
altered  capacity  of,  in  gastric  cancer, 
191 

size  of,  in  gastric  cancer,  191 
anatomic  parts,  78 
antrum  pylori  of,  80 
ascending  arm  of,  81 
atonic,  94 
benign  tumor-producing  lesions,  241 

tumors  of,  case  reports,  245-249 
body  of,  79 

cancer  of.     See  Gastric  cancer. 
carcinomatous     ulcer     of,     roentgen 

characteristics,  196 
cirrhosis  of,  214 

case  reports,  217 

characteristics,  214 

clinical  summary,  215 

roentgenologic  manifestations,  215 
dermoid  cyst  of,  241 
descending  arm  of,  80 
digestive  power  of,  Schwarz's  fibro- 

dermic  capsules  for  determining,  100 
displacement  of,  in  gastric  cancer,  191 
diverticula  of,  297 

case  report,  301 
examination  of,  75 

preparation  of  patient,  75 

supplementary  to  examination  of 
esophagus,  45 

technic,  75 
fasting,   Sahli's  opaque  capsules  for 

determining,  secretion,  99 
fibromatosis  of,  214 

case  reports,  217 

characteristics,  214 

cUnical  summary,  215 

roentgenologic  manifestations,  215 
fibrosis  of,  214 

case  reports,  217 

characteristics,  214 


INDEX    OF    SUBJECTS 


557 


Stomach,  fibrosis  of,  clinical  summary, 
215 

roentgenologic  manifestations,  215 
filling-defects  in,  from  causes  other 
than  cancer,  179 

from  extrinsic  tumors,  185 

from  faulty  media,  179 

from  pressure  against  spine,  181 

spastic,   antispasmodic  treatment, 
184 
fish-hook,  79 

acute,  in  gastric  ulcer,  266 
fixing  supports  of,  97 
flexibility    of,    lessened,    in    gastric 

cancer,  190 
foreign  bodies  in,  297 
fornix  of,  79 
fundus  of,  79 

gastrospasm  from  deformity  of  out- 
line, 163 
hair-ball  of,  292 

case-reports,  296,  297 

etiology,  294 

symptoms,  295 
hernia  mucosae  of,  299 
hour-glass,  121 

causes,  122 

congenital,  122 

gastrospasm  in,  154 

in  gastric  cancer,  179 

organic,  in  gastric  ulcer,  263 

simulation  of,  124 

spasmodic,  in  gastric  ulcer,  261 

varieties,  122,  123 
hypertonic,    92 
hypotonic,    93 
in  infancy,  forms,  314 

lack  of  peristalsis  in,  313 

normal,  313 

position,  314 
incisura  angularis  of,  79 

cardiaca  of,  79 
leather-bottle,  133,  214 

case  reports,  217 

characteristics,  214 

clinical  summary,  215 

roentgenologic  manifestations,  215 
lengthened,  309 

mobility,   lessened,   in  postoperative 
gastrojejunal  ulcer,  330 

lessened,  in  gastric  cancer,  190 


Stomach,  altered  motility  of,  in  gastric 
cancer,  189 

tests,  110 

Bassler'smixed-mealmethod,  114 
Haudek's   double-meal   method, 

114 
opaque  salts  for,  110 
vehicles  for.  111 
normal,  contour,  97 

effect  of  tone  of  musculature  on,  86 

emptying  time,  112 

fasting,  secretion  in,  99 

fish-hook,  87 

flexibihty,  99 

forms  of,  87 

gas-bubble  in,  99 

hypermotility  in,  117 

mobility,  97 

motility,  106,  116 

motor  function,  106,  107 

peristalsis  in,  100 
delayed,  105 
varieties,  102 

position,  95 

relation  of  abdominal  wall  to,  86 

retention  of  food  by,  109 

roentgen-ray  appearance,  82 

size,  96 

steer-horn,  87 

variations  of  motility  in,  107 

zone  of  motility  in,  147 
organic   deformity   of  lumenal   con- 
tour, significance,  153 
orthotonic,  92 
papillary  adenoma  of,  242 
pars  cardiaca,  of,  79 

intermedia  of,  79 

media  of,  79 

pylorica  of,  80 
polyposis,  241,  243 
position  of,  relation  to  habitus,  82-86 
post-operative  complications  in,  roent- 
genology of,  326 
recurrence  of  lesions  after  operation 

on,  341-347 
residue  in,  in  gastric  ulcer,  264 
roentgen  anatomy  of,  77 
roentgenography  of,  77 
roentgenoscopy  of,  75 
sleeve  resection,  roentgenology  after, 

322 


558 


INDEX    OF    SUBJECTS 


Stomach,  steer-horn,  79 
syphihs  of,  219 
case  reports,  224 
cirrhotic,  221 
gastric  cancer  and,  differentiation, 

224 
gummata  in,  221 
infiltrative,  221 

microscopic  examination  in,  219 
roentgenologic  manifestations,  224 
symptoms,  221,  223 
tertiary,  220 
tumor-producing,  221 
varieties,  220 
Wassermann  test  in,  219 
test  for  normal  tone,  94 
tone,  92 

alteration  of,  in  duodenal  ulcer,  403 
trichobezoar  of,  292 
ulcer  of.     See  Gastric  ulcer. 
water-trap,  143 
retention  in,  112 
Stomach-tube  and  roentgen-ray  findings 
in  gastric  motility,   comparison,    148 
Strictures,     cicatricial,     of    esophagus, 
cases,  68-70 
observation  of,  65 
Subcarbonate  of  bismuth  as  medium,  25 
Subdiaphragmatic  abscess,  appearance, 

371 
Subnitrate  of  bismuth  as  medium,  25 
Sulphate  of  barium  as  medium,  25 
Syphihs  of  stomach,  219 
case  reports,  224-239 
cirrhotic,  221 
gastric  cancer  and,  differentiation, 

224-239 
gummata  in,  221 
infiltrative,  221 

microscopic  examination  in,  219 
roentgenologic  manifestations,  224 
symptoms,  221,  223 
tertiary,  220 
tumor-producing,  221 
varieties,  220 
Wassermann  test  in,  219 
Syphilitic  gastric  ulcer,  220 
gastritis,  220 

Table,  roentgen  ray,  20 
Technic,  general,  24 


Test-breakfast,  Ewald-Boas,  108 

Test-dinner,  Leube-Riegel,  108 

Test-meals,  108 

Thorium  oxid  as  medium,  25 

Transformer,  interrupterless,  for  roent- 
gen ray,  17,  18 
roentgen  ray,  18 

Transposition  of  colon,  527 

Trichobezoar  of  stomach,  292 

Tuberculosis  of  colon,  481 
case  reports,  481-485 

Tubes,  roentgen  ray,  21 
Coolidge,  22 

Tube-stand  for  roentgenoscopy,  20 

Tumors,  extrinsic,  in  cancer  of  colon, 
filling-defects  from,  454 
of    stomach,    benign,    case    reports, 
245-249 

Ulcer,  carcinomatous,  of  stomach, 
roentgen  characteristics,  196 

duodenal.     See  Duodenal  ulcer. 

gastric.     See  Gastric  ulcer. 

gastrojejunal,  postoperative,  326. 
See  also  Gastrojejunal  ulcer,  post- 
operative. 

jejunal,  postoperative,  326.  See  also 
Gastrojejunal    ulcer,     postoperative. 

of  stomach.     See  Gastric  ulcer. 

Vehicles  for  visuaHzation,  26 
Vertical  screen    apparatus  for    fluoro- 
scopic examinations,  18 
Vicious  circle  after  gastro-enterostomy, 
case  reports,  338-341 
causes,  336-338 
roentgenology  in,  336-338 
Visualization  media,  25 
six-hour  meal  for,  28 

advantages,  29 
vehicles  for,  26 
Vomiting,  regurgitant,  after  gastro-enter- 
ostomy, case  reports,  338-341 
causes,  337 
roentgenology  in,  336-338 

Wassermann  test  in  syphilis  of  stomach, 

219 
Water-trap  stomach,  143 
retention  in,  112 

X-RAY.     See  also  Roentgen  ray. 

Zirconium  oxid  as  medium,  25 


SAUNDERS'  BOOKS 

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Rontgenology  of  the  Qastro=intestinaI  Tract.  By  Russell  D. 
Carman,  M.  D.,  Head  of  Section  on  Rontgenology,  and  Albert  Mil- 
ler, A.  B.,  M.  D;,  Second  Assistant  in  Section  on  Rontgenology, 
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This  work  takes  up  the  diagnosis  of  disease  of  the  alimentary  tract,  following 
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needed,  and  exactly  how  to  use  it,  with  formulas  for  the  barium  meal  and  enema. 
You  are  given  the  Rontgen  appearance  of  the  normal  organ  under  discussion, 
what  appearances  signify  abnormality,  and  exactly  how  to  detect  abnormality. 
Then  you  get  the  Rontgenologic  symptoms  of  every  disease  of  the  organ,  followed 
by  several  actual  examples  of  each  to  show  individual  variaf-ons,  and  an  exten- 
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DIAGNOSIS  AND    TREATMENT 


Cabot's  Works  on  Diagfnosis 

Differential  Diagnosis.  Presented  through  an  Analysis  of  Cases. 
By  Richard  C.  Cabot,  M.  D.,  Assistant  Professor  of  Clinical  Medi- 
cine, Harvard  Medical  School,  Boston.  Each  volume  an  octavo  of 
about  750  pages,  illustrated.  Per  volume  :  Cloth,  f6.oo  net. 

Dr.  Cabot's  work  takes  up  diagnosis  from  the  point  of  view  of  \he presenting 
symptovi — the  symptom  in  any  disease  which  holds  the  foreground  in  the  clinical 
picture  :  the  principal  complaint.  It  groups  diseases  under  these  symptoms,  and 
points  the  way  to  proper  reasoning  in  coming  to  a  correct  diagnosis.  It  works 
backward  from  each  leading  symptom  to  the  actual  organic  cause  of  the  symptom. 
This  the  author  does  by  means  of  case-teaching. 

The  syfuptom- groups  in  Volume  I  (Third  Edition— January,  1915)  are:  Headache,  gen- 
eral abdominal  pain,  epigastric  pain,  right  hypochondriac  pain,  left  hypochondriac  pain,  right 
iliac  pain,  left  iliac  pain,  axillary  pain,  pain  in  arms,  pain  in  legs  and  feet,  fevers,  chills, 
coma,  convulsions,  weakness,  cough,  vomiting,  hematuria,  dyspnea,  jaundice,  and  nervous- 
ness— 21  symptoms  and  385  cases. 

Volume  II  (December,  1914)  :  Abdominal  and  other  tumors,  vertigo,  diarrhea,  dyspepsia, 
hematemesis,  enlarged  glands,  blood  in  stools,  swelling  of  face,  hemoptysis,  edema  of  legs, 
frequent  micturition  and  polyuria,  fainting,  hoarseness,  pallor,  swelling  of  arm,  delirium,  pal- 
pitation  and  arhythmia,  tremor,  ascites  and  abdominal  enlargement — a  total  of  19  symptoms 
and  317  instructive  cases. 


Morrow's  Diagnostic  and 
Therapeutic  Technic 

Diagnostic  and  Therapeutic  Technic.  By  Albert  S.  Morrow, 
M.  D.,  CHnical  Professor  of  Surgery,  New  York  Polyclinic.  Octavo 
of  834  pages,  with  860  original  line  drawings.  Cloth,  $5.50  net. 

SECOND    EDITION 

Dr.  Morrow's  new  work  is  decidedly  a  work  for  you — the  physician  engaged 
:n  general  practice.  It  is  a  work  you  need  because  it  tells  you  just  how  to  perform 
ctiose  procedures  required  of  you  every  day,  and  it  tells  you  and  shows  you  by 
clear,  new  line-drawings,  in  a  way  never  before  approached.  It  is  not  a  book  on 
drug  therapy  ;  it  deals  alone  with  physical  or  mechanical  diagnostic  and  thera- 
peutic measures.  The  information  it  gives  is  such  as  you  need  to  know  every 
day — transfusion  and  infusion,  hypodermic  medication,  Bier's  hyperemia,  explora- 
tory punctures,  aspirations,  anesthesia,  etc.  Then  follow  descriptions  of  those 
measures  employed  in  the  diagnosis  and  treatment  of  diseases  of  special  regions  or 
organs:  proctoclysis,  cystoscopy,  etc. 
Journal  American  Medical  Association 

"The  procedures  described  are  those  which  practitioners  may  at  some  time  be  called 
on  to  perform.'"  Published  January,  1915 


SAUNDERS'    BOOKS   ON 


Musser  and  Kelly  on 
Treatment 

Practical  Treatment.  By  io8  eminent  specialists.  Volumes  I,  II, 
and  III,  edited  by  John  H.  Musser,  M.  D.,  and  A.  O.  J.  Kelly,  M.  D. 
Each  an  octavo  of  950  pages,  illustrated.  Cloth,  ;$6.oo  net;  Half  Mo- 
rocco, ^6.50  net.  Volume  IV,  edited  by  John  H.  Musser,  Jr.,  M.  D., 
and  Thomas  C.  Kelly,  M.  D.  Octavo  of  990  pages,  illustrated.  Cloth, 
;g7.00net;   Half  Morocco,  $8.50  net.  PubUshed  May,  1917.  Subscription. 

VOLUME  IV— All  the  New  Treatments— JUST  OUT 

With  Musser  and  Kelly's  Treatment  within  arm's  reach  you  have  at  your 
instant  command  the  combined  experience  and  teachings  of  108  leading  internists 
and  specialists  of  America  and  England.  In  many  cases  you  get  the  actual pre- 
scrzp f ions  used  hy  these  authorities.  The  past  few  years  have  seen  radical  de- 
velopments in  medicine  ;  it  is  these  new  developments  that  constitute  the  subject- 
matter  of  Volume  IV.  Bacteriology,  the  endocrine  glands,  serum  therapy,  syn- 
thetic chemistry,  new  surgical  and  non-medical  treatments — these  are  only  a  few 
of  the  subjects  covered.  Remember,  Musser  and  Kelly's  Treatment  covers  the 
entire  field.  It  is  a  Treatment  that  will  give  you  more  service — better  service — 
han  any  other. 


Thomson's   Clinical   Medicine 

Clinical  Medicine.     By  William  Hanna  Thomson,  M.  D.,  LL.  D., 

formerly  Professor  of  the   Practice  of  Medicine  and  of  Diseases  of  the 

Nervous  System,  New  York   University  Medical  College.     Octavo  of 

675  pages.  Cloth,  ;^5.oo  net;  Half  Morocco,  ^6.50  net. 

TWO  PRINTINGS  IN  FOUR  MONTHS 

This  new  work  represents  over  a  half  centttry  of  active  practice  and  teach- 
i7ig.  It  deals  with  bedside  medicine — the  applicatio7i  of  medical  knowledge  for 
the  relief  of  the  sick.  First  the  meaning  of  common  and  important  symptoms  is 
stated  definitely ;  then  follows  a  chapter  on  the  use  of  remedies  and  a  classifi- 
cation of  them  ;  next  the  section  on  infections,  and  last  a  section  on  diseases  of  par- 
ticular organs  and  tissues.  It  is  medical  knowledge  applied — from  cover  to  cover. 
An  important  chapter  is  that  on  the  mechanism  of  surface  chill  and  "catching 
cold,"  going  very  clearly  into  the  etiologic  factors,  and  outlining  the  treatment. 
The  chapter  on  remedies  takes  up  non-medicinal  and  medicinal  remedies  and 
vaccine  and  serum  thera^py.  In  the  chapter  on  the  ductless  glands  the  subject  of 
inter7ial  secretions  is  \exy  clearly  presented,  giving  you  the  latest  advances.  The 
infectious  diseases  are  taken  up  in  Part  II,  while  Part  III  deals  with  diseases  of 
ipecial  organs  or  tissues,  every  disease  being  fully  presented  from  the  clinical 
side.     Treatment,  naturally,  is  very  full.  Published  Ju^i^,  1^14 


PRACTICE    OF  MEDICINE 


Ward's  Bedside  Hematolog'y 

Bedside  Hematology.  By  Gordon  R.  Ward,  M.D.,  Fellow  ol  the 
Royal  Society  of  Medicine,  London,  England.  Octavo  of  394  pages, 
illustrated.    Published  April,  1914.  Cloth,  ^3.50  net. 

INCLUDING  VACCINES  AND  SERUMS 

Dr.  Ward's  work  gives  you  the  exact  technic  for  obtaining  the  blood  for  ex- 
amination, the  making  of  smears,  the  blood-count,  finding  coagulation  time,  etc, 
Then  it  takes  up  each  disease,  giving  you  the  synonyms,  definition,  nature,  gen- 
eral pathology,  etiology,  bearings  of  age  and  sex,  the  onset,  symptomatology  (dis- 
cussing each  symptom  in  detail),  course  of  the  disease,  clinical  varieties,  compli- 
cations, diagnosis,  and  treatment  (drug,  diet,  rest,  vaccines  and  sertans,  etc.). 


Faught*s  Blood-Pressure 

Blood = Pressure  from  the  Clinical  Standpoint.  By  Francis  A. 
Faught,  M.  D.,  formerly  Instructor  :n  Medicine,  Medico-Chirurgical 
College  of  Philadelphia.  Octavo  of475  pages,  illustrated.  Cloth,  ^3.25  net. 

SECOND  EDITION— published  November.   1916 

Dr.  Faught' s  book  is  designed  for  practical  help  at  the  bedside.  Besides  the 
actual  technic  of  using  the  sphygmomanometer  in  diagnosing  disease,  Dr.  Faught 
has  included  a  brief  general  discussion  of  the  process  of  circulation.  The  practical 
application  of  sphygmomanometric  findings  within  recent  years  make  it  imperative 
for  every  medical  man  to  have  close  at  hand  an  up-to-date  work  on  this  subject. 


Smith's  What  to  Eat  and  Why 

What  to  Eat  and  Why.     By    G.    Carroll   Smith,  M.D.,  Boston. 

I2mO  of  377  pages.       Cloth,  $2.75  net.  Published  September,  1915 

SECOND  EDITION 

With  this  book  you  no  longer  need  send  your  patients  to  a  specialist  to  be 
dieted — you  will  be  able  to  prescribe  the  suitable  diet  yourself  just  as  you  do 
other  forms  of  therapy.  Dr.  Smith  gives  the  "why"  of  each  statement  he 
makes.  It  is  this  knowing  why  which  gives  you  confidence  in  the  book,  which 
makes  you  feel  that  Dr.  Smith  knows. 

Pennsylvania  Medical  Journal 

"All  through  this  book  Dr.  Smith  has  added  to  his  dietetic  hints  a  great  many  valuable  ones 
oi  a  general  nature,  which  will  appeal  to  the  general  practitioner 


SAUNDERS'   BOOKS    ON 


Kolmer's  Specific  Therapy 

Infection,  Immunity,  and  Specific  Therapy.  By  John  A.  Kolmer, 
M,  D.,  Dr.  p.  H.,  Assistant  Professor  of  Experimental  Pathology,  Uni- 
versity of  Pennsylvania.  Octavo  of  900  pages,  with  143  original  illus- 
trations, 43  in  colors,  drawn  by  Erwin  F.  Faber.  New  (2d)  Edition  ready 
August.  1917. 

ORIGINAL  ILLUSTRATIONS 

Dr.  Kolmer's  book  gives  you  a  full  account  of  infection  and  immunity,  and 
the  application  of  this  knowledge  in  the  specific  dia,gnosis,  prevention,  and  treat- 
ment of  disease.  The  section  devoted  to  immunologic  techtiic  gives  you  every  de- 
tail, from  the  care  of  the  centrifuge  and  making  a  simple  pipet  to  the  actual  pro- 
duction of  serums  and  vaccines.  Under  specific  therapy  you  get  methods  of 
making  autogenous  vaccines  and  their  actual  use  in  diagnosis  and  treatment.  The 
directions  for  injecting  vaccines,  serums,  salvarsan,  etc.- — with  the  exact  dosage — 
are  here  given  so  clearly  that  you  will  be  able  to  use  these  means  of  treatment  in 
your  daily  practice.  You  also  get  full  directions  for  making  the  clinical  diagnostic 
reactions — the  various  tuberculin  tests,  luetin,  mallein,  and  similar  reactions,  all  illus- 
trated with  colored  plates.     The  final  section  is  devoted  to  laboratory  experiments. 


Anders  £^  Boston's  Medical  Diag'nosis 

(Published  July,  1914) 

A  Text-Book  of  Medical  Diagnosis.  By  James  M.  Anders,  M.  D., 
Ph.D.,  LL.D.,  Professor  of  Medicine,  and  L.  Napoleon  Boston,  M.D., 
Professor  of  Physical  Diagnosis,  Medico-Chirurgical  College,  Graduate 
School  of  Medicine,  University  of  Pennsylvania.  Octavo  of  1 248  pages, 
with  466  illustrations.     Cloth,  |6.oo  net ;  Half  Morocco,  ;^7.50  net. 

SECOND  EDITION 

This  new  edition  is  designed  expressly  for  the  general  practitioner.  The 
methods  given  are  practical  and  especially  adapted  for  quick  reference.  The 
diagnostic  methods  are  presented  in  a  forceful,  definite  way  by  men  who  have 
had  wide  experience  at  the  bedside  and  in  the  clinical  laboratory. 

The  Medical  Record 

"  The  association  in  its  authorship  of  a  celebrated  clinician  and  a  well-known  laboratory 
worker  is  most  fortunate.     It  must  long  occupy  a  pre-eminent  position." 


THE  PRACTICE    OF  MEDICINE 


Anders' 
Practice   of  Medicine 


A  Text=Book  of  the  Practice  of  Medicine.  By  James  M.  Anders, 
M.  D.,  Ph.  D.,  LL.  D.,  Professor  of  Medicine,  University  of  Pennsylvania. 

Handsome  octavo,  1336  pages,  fully  illustrated.     Cloth,  $5.50  net;  Half 

Morocco,    ^7.00    net.  Published  September,  1915 

TWELFTH  EDITION 

The  success  of  this  work  is  no  doubt  due  to  the  extensive  consideration  given 
to  Diagnosis  and  Treatment,  under  Differential  Diagnosis  the  points  of  distinction 
of  simulating  diseases  being  presented  in  tabular  form.  In  this  new  edition 
Dr.  Anders  has  included  all  the  most  important  advances  in  medicine,  keeping 
the  book  within  bounds  by  a  judicious  elimination  of  obsolete  matter.  A  great 
many  articles  have  also  been  rewritten. 

Wm.  E.  Quine,  M.  D., 

Professor  of  Medicine  and  Clinical  Medicine,  College  of  Physicians  and  Surgeons,  Chicago. 
"  I  consider  Anders'  Practice  one  of  the  best  single-volume  works  before  the  profession  at 
this  time,  and  one  of  the  best  text-books  for  medical  students." 


DaCosta's  Physical  Dia^^nosis 

Physical  Diagnosis.  By  John  C.  DaCosta,  Jr.,  M.  D.,  Associate 
Professor  of  Medicine,  Jefferson  Medical  College,  Philadelphia.  Octavo 
of  589  pages,  with  243  original  illustrations.  Cloth,  $3.50  net 

THIRD  EDITION— published  November,  1915 

Dr.  DaCosta' s  work  is  a  thoroughly  new  and  original  one.  Every  methodi 
given  has  been  carefully  tested  and  proved  of  value  by  the  author  himself. 
Normal  physical  signs  are  explained  in  detail  in  order  to  aid  the  diagnostician  in 
determining  the  abnormal.  Both  direct  and  differential  diagnosis  are  emphasized. 
The  cardinal  methods  of  examination  are  supplemented  by  full  descriptions  of 
technic  and  the  clinical  utility  of  certain  instrumental  means  of  research. 

Dr.  Henry  L.   Eisner,   Professor  of  Medicine  at  Syracuse  University. 

"  I  have  reviewed  this  book,  and  am  thoroughly  convinced  that  it  is  one  of  the  best  ever 
written  on  this  subject.     In  every  way  I  find  it  a  superior  production." 


SAUNDERS'    BOOKS   ON 


Norris  ^  Landis*  Physical 
Diagnosis 

Phy.sical  Diagnosis.  Part  I :  By  George  William  Norris,  A.  B., 
M.  D.,  Associate  in  Medicine  at  the  University  of  Pennsylvania ;  Part  II : 
By  H.  R.  M.  Landis,  A.  B.,  M.  D.,  Director  of  Clinical  and  Sociological 
Department  of  the  Phipps  Institute,  Philadelphia.  Octavo  of  8oo 
pages,  with  325  illustrations,  mostly  original. 

STRONG   ON   INTERPRETATION 

This  work  presents  an  admirable  combination  of  the  theory  and  applications 
of  physical  diagnosis.  It  is  complete  down  to  the  last  detail.  The  first  part  takes 
up  the  methods  in  themselves.  Inspection,  palpation,  percussion,  and  ausculta- 
tion are  completely  covered  in  the  examination  both  of  the  lungs  and  of  the  heart. 
The  latter  is  ampHfied  by  a  chapter  on  the  electrocardiograph  by  Dr.  Edward  B. 
Krumbhaar.  The  second  part  takes  up  the  particular  diseases  of  the  bronchii,  of 
the  lungs,  of  the  pleura,  diaphragm,  pericardium,  heart  and  aorta,  and  shows  you 
exactly  how  to  determine  the  diagnosis  by  the  symptoms  and  findings.  You  get 
here  the  application  of  the  four  methods  to  your  daily  clinical  work. 

r  riedenwald  and  Ruhrah  on  Diet 

Diet  in  Health  and  Disease.  By  Julius  Friedenwald,  M.  D., 
Professor  of  Diseases  of  the  Stomach,  and  John  Ruhrah,  M.  D.,  Pro- 
fessor of  Diseases  of  Children,  College  of  Physicians  and  Surgeons, 
Baltimore.      Octavo  of  857  pages.  Published  juiy,  1913.  Cloth,  ^4.00  net. 

FOURTH   EDITION 

This  new  edition  has  been  carefully  revised,  making  it  still  more  useful  than  the  two 
xditions  previously  e.xhausted.  The  articles  on  milk  and  alcohol  have  been  rewritten,  additions 
made  to  those  on  tuberculosis,  the  salt-free  diet,  and  rectal  feeding,  and  several  tables  added, 
including  Winton's,  showing  the  composition  of  diabetic  foods. 

•George  Dock,  M.  D. 

Professor  of  Theory  a?id  Practice  and  of  Clinical  Medicine,    Tulane   University. 
"  It  seems  to  me  that  you  have  prepared  the  most  valuable  work  of  the  kind  now  available, 
I  am  especially  glad  to  see  the  long  list  of  analyses  of  different  kinds  of  foods." 

Carter's  Diet  Lists 

Diet  Lists  of  the  Presbyterian  Hospital  of  New  York  City. 
Compiled,  with  notes,  by  Herbert  S.  Carter,  M.  D.  i2mo  of  129 
pages.  Pubii;i2cd  :.:c:;-,  1913  Cloth,  $1.00  net. 

Here  Dr.  Cnrter  has  cimpilrd  nil   the  diet  lists  for  the  various  diseases  and  for  conva- 
lescence as  prescribed  at  the  Presbyterian  Hospital.      Recipes  are  also  included. 


PRACTICE    OF  MEDICINE 


Kemp  on  Stomach, 
Intestines,  and  Pancreas 

Diseases  of  the  Stomach,  Intestines,  and  Pancreas.  By  Robert 
Coleman  Kemp,  M.  D.,  Professor  of  Gastro-intestinal  Diseases  at  the 
New  York  School  of  Clinical  Medicine.  Octavo  of  1096  pages,  with 
428  illustrations.     Cloth,  $7.00  net ;   Half  Morocco,  $8.50  net, 

NEW  (3d)  EDITION— published  April.   1917 

The  new  edition  of  Dr.  Kemp's  successful  work  appears  after  a  most  search- 
ing revision.  Several  new  subjects  have  been  introduced,  notably  chapters  on 
Colon  Bacillus  Iiifectio?i  and  on  Diseases  of  the  Pattcreas,  the  latter  article  being 
really  an  exhaustive  monograph,  covering  over  one  hundred  pages.  The  section 
on  Duodenal  Ulcer  has  been  entirely  rewritten.  Visceral  Displacements  are  given 
special  consideration,  in  every  case  giving  definite  indications  for  surgical  inter- 
vention when  deemed  advisable.  There  are  also  important  chapters  on  the  Intes- 
tinal  Complications  of  Typhoid  Fever  and  on  Diverticulitis.  ' 

The  Therapeutic  Gazette 

"The  therapeutic  advice  which  is  given  is  excellent.  Methods  of  physical  and  clinical 
examinadon  are  adequately  and  correctly  described." 


Gant  on  Diarrheas 

Diarrheal,  Inflammatory,  Obstructive,  and  Parasitic  Diseases  of 
the  Qa5tro=intestinal  Tract.  By  Samuel  G.  Gant,  M.  D.,  LL.D., 
Professor  of  Diseases  of  Sigmoid  Flexure,  Colon,  Rectum,  and  Anus, 
New  York  Post-graduate  Medical  School  and  Hospital.  Octavo  of  604 
pages,  181  illustrations.     Cloth,  ^6.00  net;  Half  Morocco,  ^^7. 50  net. 

ILLUSTRATED 

This  new  work  is  particularly  full  on  the  two  practical  phases  of  the  subject — 
diagnosis  and  treatment.  For  instance  :  While  the  essential  diagnostic  points  are 
given  under  each  disease,  a  fuller  description  of  diagnostic  methods  is  given  in  a 
special  chapter.  The  differential  diagnosis  of  diarrheas  of  local  and  those  of  sys- 
temic disturbances  is  strongly  brought  out.  There  is  a  special  chapter  on  ner- 
vous diarrheas  and  those  originating  from  gastrogenic  and  e7iterogenic  dyspepsias. 
You  get  methods  of  simultaneously  controlling  associated  constipation  and  diar- 
rhea. You  get  a  complete  formulary.  The  limitations  of  drugs  are  pointed  out, 
and  the  indications  and  techtiic  of  all  surgical  procedures  given.  June,  1915 

Gant  on  Constipation  and  Obstruction 

This  Avork  is  medical,  non-medical  (mechanical),  and  surgical,  the  latter  really 
being  a  complete  work  on  rectocolonic  surgery.  Second  Edition  October,  1916 

Octavo  of  575  pages,  with  250  illustrations.     By  SAMUEL  G.  Gant,  M.  D.     Cloth,  ^6.00  net. 


SAUNDERS'    BOOKS   ON 


Sollmann*s   Pharmacology 

A  Manual  of  Pharmacology :  Its  Applications  to  Therapeutics 
AND  Toxicology.  By  Torald  Sollmann,  M.  D.,  Professor  of  Pharma- 
cology and  Materia  Medica  in  the  School  of  Medicine  of  Western  Re- 
serve University,  Cleveland.     Octavo  of  901  pages,  illustrated.     Cloth, 

^4.50  net.  Published  February,  1917 

JUST  OUT— BASED  ON  THE  1916  U.  S.  PHARMACOPOEIA 

lyt  A  jaij  A  f  ^  This  is  the  text  or  reference  volume.  Two  sizes  of  type  are 
used.  The  broad  conceptions,  the  generalizations,  and  those 
detailed  discussions  of  great  and  practical  value  to  practitioner  and  student  are  set 
in  the  large  type.  The  mass  of  minute  details  is  set  in  the  smaller  type,  with 
frequent  side  headings  to  facilitate  quick  reference.  Throughout  the  work  the 
relation  of  pharmacology  to  the  practice  of  medicine  is  forcibly  emphasized.  The 
really  important  drugs — those  drugs  that  you  actually  use  in  your  practice — are 
discussed  extensively,  while  those  used  less  frequently  are  dismissed  with  less  con- 
sideration. All  the  new  remedies  are  included,  with  detailed  instructions  for  their 
use  :  Vaccines,  serums,  salvarsan,  neosalvarsan,  pituitary  extract,  emetin — all 
those  new  remedies  of  the  Pharmacopoeia  being  so  extensively  discussed  and  em- 
ployed.     Every  worthwhile  development  in  the  field  of  pharmacology  is  included. 

LABOR.AXORY    GUIDES.     '^^^   exercises  in   this   Laboratory   Grade 

present  no  difficulty  in  technic,  and  re- 
quire little  help  from  the  instructor.  They  teach  you  how  to  teach  yourself.  Special 
stress  is  laid  on  facts  with  direct  practical  bearing.  The  experiments  on  animals 
are  arranged  in  groups  to  illustrate  various  types  or  phenomena,  to  bring  out  the 
similarities  and  differences  of  the  response  of  organs  to  pharmacologic  agents, 
rather  than  to  individual  drugs.  This  arrangement  articulates  better  with  the 
student's  experience  in  physiology  and  pathology. 

A    Labomiory  Guide  in  Pharmacology.    By  Torald  Sollmann,  M.  D.    Octavo  of  355  pages,  illustrated. 
Cloth,  $2.50  net. 

Amy's  Pharmacy 

Principles  of  Pharmacy.  By  Henry  V.  Arny,  Ph.  D.,  Professor 
of  Chemistry,  New  York  College  of  Pharmacy.  Octavo  of  1056  pages, 
with  246  illustrations.     Cloth,  $5.50  net;  Half  Morocco,  $7.00  net. 

SECOND  EDITION— published  March,  1917 

Professor  Arny  divides  his  book  into  seven  parts:  The  first  part  deals  with  phar- 
maceutic processes,  a  striking  feature  being  the  clear  discussion  of  the  arithmetic 
of  pharmacy;  the  second,  with  galenic  preparations  of  the  Pharmacopoeia  and  those 
unofficial  preparations  of  proved  value;  the  third,  with  the  inorganic  chemicals, 
including  the  theories  of  chemistry;  the  fourth  discusses  the  organic  chemicals; 
the  fifth  is  devoted  to  chemical  testing,  presenting  a  systematic  grouping  of  all 
the  tests  of  the  Pharmacopoeia ;  the  sixth  discusses  the  prescription  from  the  time 
it  is  written  until  it  is  dispensed;  the  seventh  is  devoted  to  laboratory  work,  with 
exercises  in  equation  writitig  and  chemical  arithmetic . 

George  Reimann,  Ph.  G.,  Secretary  New  York  State  Board  of  Pharmacy 

"  I  would  say  that  the  book  is  certainly  a  great  help  to  the  student,  and  I  think  it  ought  to 
be  in  the  hands  of  every  person  who  is  contemplating  the  study  of  pharmacy." 


THERAPEUTICS  AND   EXERCISE 


Bastedo's   Materia   Medica 

Pharmacology,    Therapeutics,    Prescription     Writing 

Materia  Medica,  Pharmacology,  Therapeutics,  and  Prescription 
Writing.  By  W.  A.  Bastedo,  Ph.  D.,  M.  D.,  Associate  in  Pharma- 
cology and  Therapeutics  at  Columbia  University,  New  York.     Octavo 

of  602  pages,  illustrated.  New  (2d)  Edition  ready  soon 

THREE  PRINTINGS  IN  SIX  MONTHS 

Dr.  Bastedo's  discussion  of  his  subject  is  very  complete.  As  an  illustration, 
take  the  pharmacologic  action  of  the  drug.  It  gives  you  the  antiseptic  action,  the 
local  action  on  the  skin,  mucous  membranes,  and  the  alimentary  tract  ;  where  the 
drug  is  obsorbed,  if  at  all — and  how  rapidly.  It  gives  you  the  systemic  action  on  the 
circulatory  organs,  respiratory  organs,  nervous  system,  and  sense  organs.  It  tells 
you  how  the  drug  is  changed  in  the  body.  It  gives  you  the  route  of  elimination 
and  in  what  form.  It  gives  you  the  action  on  the  kidneys,  bladder,  urethra,  skin, 
bowels,  lungs,  and  mammary  glands  during  elimination.  It  gives  you  the  after- 
effects. It  gives  you  the  unexpected — the  unusual — effects.  It  gives  you  the 
tolerance — habit  formation.  Could  any  discussion  be  more  complete,  more 
thorough  ? 

Boston  Medical  and  Surgical  Journal 

"  Its  aim  throughout  is  therapeutic  and  practical,  rather  than  theoretic  and  pharmacologic. 
The  text  is  illustrated  with  sixty  well-chosen  plates  and  cuts.  It  should  prove  a  useful  con- 
tribution to  the  text-book  literature  on  these  subjects." 


McKenzie  on  Exercise  in 
Education    and    Medicine 

Exercise  in  Education  and  Medicine.    By  R.  Tait  IMcKenzie,  B.  A. 

M.  D.,  Professor  of  Physical  Education  and  Director  of  the  Department, 

University  of  Pennsylvania.     Octavo  of  585   pages,  with  478  original 

illustrations.  Cloth,  $4.00  net. 

SECOND  EDITION— published  June.   1915 

D.  A.   Sargeant.   M.   D.,   Director  of  Hetnenway  Gymnasium,  Harvard  Uni'^ersity. 

"It  cannot  fail  to  be  helpful  to  practitioners  in  medicine.  The  classification  of  athletic 
games  and  exercises  in  tabular  form  for  different  ages,  sexes,  and  occupations  is  the  work  of  an 
expert.     It  should  be  in  the  hands  of  every  physical  educator  and  medical  practitioner." 

Bonney's  Tuberculosis  second  Edition 

Tuberculosis.  By  Sherman  G.  Bonney,  M.  D.,  Professor  of  Medi- 
cine, Denver  and  Gross  College  of  Medicine.  Octavo  of  955  pages,  with 
243  illustrations.     Cloth,  $7.00  net ;  Half  Morocco,  ^8.50  net. 

Maryland  Medical  Journal 

"  Dr.  Bonney's  book  is  one  of  the  best  and  most  exact  works  on  tuberculosis,  in  all  its 
aspects,  that  has  yet  been  published."  Published  May,  1910 


12  SAUNDERS'    BOOKS   ON 


Garrison's 
History  of  Medicine 

History  of  Medicine^  With  Medical  Chronology,  Bibliographic 
Data,  and  Test  Questions.  By  Fielding  H.  Garrison,  M.  D.,  Prin- 
cipal Assistant  Librarian,  Surgeon-General's  Office,  Washington,  D.  C. 

Cloth,  ^6.00  net;    Half  Morocco,  ^7.50  net.  Published  December,  1913 

REPRINTED  IN  THREE  MONTHS— THE  BAEDEKER  OF  MEDICAL  HISTORlf 

The  work  begins  with  ancient  and  primitive  medicine,  and  carries  you  in  a 
most  interesting  and  instructive  way  on  through  Egyptian  medicine,  Sumerian 
and  Oriental  medicine,  Greek  medicine,  the  Byzantine  period  ;  the  Mohammedan 
and  Jewish  periods,  the  Medieval  period,  the  period  of  the  Renaissance,  the  Re- 
vival of  learning  and  the  Reformation  ;  the  Seventeenth  Century  (the  age  of  indi- 
vidual scientific  endeavor),  the  Eighteenth  Century  (the  aye  of  theories  and 
systems),  the  Nineteenth  Century  (the  beginning  of  organized  advancement  of 
science),  the  Twentieth  Century  (the  beginning  of  organized  preventive  medicine). 
You  get  all  the  important  facts  in  medical  history;  a  biographic  dictionary;  an 
album  of  7nedical portraits;  and  a  complete  jnedical  chronology. 

Stevens*    Therapeutics  Fifth  Edition,  September,  1909 

A  Text-Book  of  Modern  Materia  Medica  and  Therapeutics. 
By  A.  A.  Stevens,  A.  M.,  M.  D.,  Lecturer  on  Physical  Diagnosis  in 
the  University  of  Pennsylvania.     Octavo  of  675  pages.     Cloth,  ^3.50  net. 

Dr.  Stevens'  Therapeutics  is  one  of  the  most  successful  works  on  the 
subject  ever  published.  In  this  new  edition  the  work  has  undergone  a 
very  thorough  revision,  and  now  represents  the  very  latest  advances. 

The  Medical  Record,  New  York 

"  Among  the  numerous  treatises  on  this  most  important  branch  of  medical  practice, 
this  by  Dr.  Stevens  has  ranked  with  the  best." 

Butler's  Materia  Medica  sixth  Edition 

A  Text-Book  of  Materia  Medica,  Therapeutics,  and  Pharma- 
cology. By  George  F.  Butler,  Ph.  G.,  M.  D.,  Professor  and  Head 
of  the  Department  of  Therapeutics  and  Professor  of  Preventive  and 
Clinical  Medicine,  Chicago  College  of  Medicine  and  Surgery,  Medical 
Department  Valpariso  University.  Octavo  of  702  pages,  illustrated. 
Cloth,  ^4.00  net;  Half  Morocco,  ^5.50  net.  Published  June,  i908 

For  this  sixth  edition  Dr.  Butler  has  entirely  remodeled  his  work,  a  great 
part  having  been  rewritten.  All  obsolete  matter  has  been  eliminated,  and 
special  attention  has  been  given  to  the  toxicologic  and  therapeutic  effects 
of  the  newer  compounds. 

Medical  Record,  New  York 

■'  Nothing  has  been  omitted  by  the  author  which,  in  his  judgment,  would  add  to  the 
completeness  of  the  text." 


THERAPEUTICS  AND  MATERIA   MEDICA  13 

Tousey's  Medical  Electricity 
R6ntg(en  Rays,  &nd  Radium 

Medi<:al  Electricity,  Rontgen  Rays,  and  Radium.  By  Sinclair 
TousEY,  M.  D.,  Consulting  Surgeon  to  St.  Bartholomew's  Hospital, 
New  York.  Octavo  of  1219  pages,  with  801  illu.strations,  ig  in  colors. 
Cloth,  $7.50  net;   Half  Morocco,  ;$9.oo  net.  PubUshed  February,  1915 

SECOND  EDITION,  RESET 

The  revision  for  this  edition  was  extremely  heavy  ;  new  matter  has  increased  the  size 
of  the  book  by  some  loo  pages.  About  50  new  ilkistrations  have  been  added.  The  new 
matter  added  includes :  Diathermy,  sinusoidal  currents,  radiography  with  intensifying 
screens,  rontgenotherapy,  the  Coolidge  and  similar  Rontgen  tubes  and  the  author's  method 
of  dosage,  and  radium  therapy  are  noted.  The  booli  has  been  enriched  by  including  several 
of  Machado's  tabular  classifications  of  electric  methods,  effects,  and  uses. 

Throughout  the  entire  work  everything  concerning  electricity,  x-rays,  and  radium  in 
medicine,  as  well  as  phototherapy,  is  explained  in  detail — nothing  is  omitted.  It  tells  you 
how  to  equip  your  office,  and,  more  than  that,  how  to  use  your  apparatus,  explaining  away 
all  difficulties.  It  tells  you  just  how  to  apply  these  measures  in  the  treatment  of  disease. 
The  chapters  on  dental  radiography  are  particularly  valuable  to  those  interested  in  dental 
work. 


Deaderick  C^  Thompson's  Endemic 
Diseases  of  South 

Endemic  Diseases  of  the  Southern  States.  By  William  H. 
Deaderick,  M.  D.,  Member  American  Society  of  Tropical  Medicine  ; 
and  LoYD  Thompson,  M.  D.,  Charter  Member  American  Association 
of  Immunologists.  Octavo  of  546  pages,  illustrated.  Cloth,  ;^5.oo 
net;   Half  Morocco,  36.50  net.  Published  March,  1516 

THE  ONLY  WORK  OF  ITS  KIND 

This  work  records  the  experiences  of  two  active  practitioners  and  teachers 
right  in  the  field  arid  thoroughly  familiar  with  these  diseases.  Those  diseases  of 
special  importance  are  given  unusual  consideration.  Pellagra,  for  instance,  is 
given  eight  chapters  for  its  full  consideration,  while  hookworm  disease  covers  nine 
chapters  and  malaria  eight.  You  get  the  etiology,  pathology,  clinical  history, 
diagnosis,  prognosis,  prophylaxis,  and  treatment  of  each  disease,  presented  from 
every  angle,  always  bearing  in  mind  the  practical  aim  of  the  work — the  application 
of  the  knowledge  in  daily  practice. 


SAUNDERS'    BOOKS   ON 


GET  A  •  THE  NEW 

THE  BEST  t\  111  6  n  C  Ci  11  STANDARD 

Illustrated    Dictionary 


New    8th     Edition— 1500  New  Words 

The  American  Illustrated  .Hedical  Dictionarj' By  W.  A.  New- 
man Borland,  M.  D..  Editor  of  "  The  American  Pocket  Medical  Dic- 
tionan-."  Large  octavo  of  1 1 37  pages,  bound  in  full  flexible  leather. 
Price,  ^50  net ;  witli  thumb  index,  $$.00  net.  PaWshed  August,  ipis 

KEY  TO  CAPITALIZATION  AND  PRONUNCIATION— ALL  THE  NEW  WORDS 

Hovrard  A.  Ytie^iliy,\A.S}.,Prcfezsor  of  Gynecologic  Surgery ,  Johns  Hopkins  University. 

"  Dr.  Dorland's  dictionary  is  admirable.     It  is  so  well  gotten  up  and  of  such  convenient 

size.     No  errors  hare  been  fonnd  in  kit  use  of  it." 


Thornton's   Dose^Book.  Fourth  Edition 

Dose-Book  asd  Mastaiof  PREscajpnoN-WRinNG.     By  E.  Q.  Thornton,  M.D., 

Assistant  Professor  of  Materia  Medica,  Jefferson  Medical  College,  Philadelphia.  Post- 
ocmTO,  410  pages,  illustrated.     Flexible  leather,  $2.00  net.  Published  September,  1909 

"  I  -win  be  able  10  make  considerable  use  of  that  part  of  its  contents  relating  to  the  correct 
terminology  as  used  in  prescription-'vrriting,  and  it  will  afford  me  much  pleasure  to  recom- 
mend the  book  to  my  classes,  ■who  often  fail  to  find  this  information  in  their  other  text- 
books."— C.  H.  Miller,  '^l. T).,  Professor  of  Pharmacology,  Northivestem  University  Medi- 
zrJ  School. 

Lusk    on    Nutrition  Wei^r  (3d)  Edition 

Elements  or  tttf.  Science  or  NrrEinoN.     By  Gbah.am  LrsK,  Ph.  D.,  Professor 

of   Ph^-siology  in    Cornell   Tniversitx-  Medical  School.     Octavo  of  641  pages.      Cloth, 

$4.50  net.  Published  July,  1917 

"  I  shall  recommend  it  highly.  It  is  a  comfort  to  hare  ssch  a  discussion  of  the  subject," 
— LrTrTELLYS  F.  Bailkee.,  M.  Ti.,  Johns  Hopkins  University'. 

Camac's  "Epoch-ma.king  Contributions" 

Z?:cH-i»?AKiNG  CoNTRiBraoNS  IN  MEDICINE  AND  SuRGERY.  Collected  and 
srri.—^'zi  ry  C.  N.  B.  Camac,  M.  D.,  of  New  York  City.  Octavo  of  450  pages,  illus- 
trated.    Artistically  bonnd,  ^00  net  Published  January,  1909 

"  Dr.  Camac  has  provided  us  with  a  most  interesting  aggregation  of  classical  essays^ 
We  hope  that  members  of  the  profession  will  show  their  appreciation  of  his  endeavors."— 
lBERA,PEUTic  Gazette. 


PRACTICE,    MATERIA  MEDICA,   E^. 


The  American  Pocket  Medical  Dictionary  New    9tfi    Edmcn 

The  AiiEsi'jAN  P'jcket  MeX'IO»_l  DicnoiN'AaT.  E.iited  by  W.  A.  'STxyu^^  L'oa 
lA>rD,  AL  D.,  JiaiiDr  •' Araerlcan  in usiiared  Medical  Dicucnarv.''  6ct  pages.  Flex; hie 
leatKer,  with  gold  edges,  St.25  net  j  wiifa.  dnimh  index,  $1.50  neu  ''  '  AartL  1915 

Strouse  d  Perry's  Food  Manual  for  Doctor  and  Patient 

A  FCiOD  i'LA^TTAL  FOR  DCCTOR  AST)  Pattest.  Bv  sorojiG^T  SrsouHE,  A.  B.,  M-  D^ 
Professor  or  Medicine.  Post-Graduate  Medical  SdiooL  Chicago:  and  M-aude  ^ 
Persy,  B.  5.,  Dietitian  ilicliael  Reese  Hospital,     rzmo  of  27c  pages.     Clotli-  $1.50 

net.  Po&ii^ed  Arrgpint-j  1917 

Here  the  science  of  rartritron  is  detailed  for  the  layman,  and.  the  physcLsn  frnrfs 

his  abstract  theories  translated  into  the  terminology  of  the  kitchsL  Diets  are  givtai 
for  diabetes  {starvation  treatmenfi .  gout,  nephritis.  Hgrfi  blood-pressure,  kidney  stone, 
diseases  of  the  stomach,  rntestrnes.  liver.  galL-stones.  tabenroloss.  fevos.  -l-rrt  nfec- 
tions,  obesity,  ant^mfa..  etc.  There  are  in  att  232  diets  and  memsj  aTrd  124  fecial 
redpes. 

Cohen  and  Eshner's  Diagnosis.  Second  ReviMd  c^fitun.  laaa 

EsszvTTALS  OF  Dr.iG>X'Sis.  By  5.  .-^OLrs-CoHZ^r.  M.  Z.,  Senicr  A^sisajt  Prufiaaur 
in  Clinical  Medicine.  Jeirerson  Medical  College,  PMLi-  :  and.  A.  A.  EsencS,.  M.  D.,, 
Professor  of  Qinical  Medicine.  Philadelpoia  Polyclinic.  Past-actavo.  ^^  pa^es  7  ?? 
illustradons.      Qodi,  51.25  nee     Zn  Sarundir^  Qu£sdan-CjmiTiim.i  Serids:. 

Morris'  Materia  Medica  and  Therapeutics-  Se»«ntfe  JL&Ssm. 

EiiENTiALi  ;?  MArEs.i.A  Me2ICa.  ~^^-^  A--T— ■— -  A5D  FRES^RrPTTC^'■-"W"s^rT^'"(T. 
By  Hently  Morris,  M.  D.,  late  T'emonsxrarcr  of  Tienipeuiics.  Jefescn  Meiicn 
College.  Phila.  Revised  by  W.  A.  Basteto,  M.  D..  Instractor  in  ilaterra  3fedrca.aiid 
Pharmacologv  at  Coltnnbia  Unive."5iEy=  I2nio.  jOfj^ages.  Clctii,  51.J5  neu  jji  Sajuide^' 
Qtusiijn-Cam^ditd  Series.  Pabiished  yoven&ar.  1905 

Kelly's  Cyclopedia  of  American  Medical  Bioigraphy 

Cyclopedia  of  AitERicAy  MsDCCAi  Biv^aRAPSY.  Zy  Hottarj:'  A.  Kejilt.  iL  D.. 
Johns  Hopkins  University.  Two  octavos  of  5.15  pages  each,  with  poiTrait5.  Per  ser 
Cloth.  1 10.00  net ;   Half  Morocco.  5x3.00  net.  PoMi^ed  Aani.  rai2 

Oertel  on  Bright's  Disease  ffluatrated 

The  A>'AToinc  Histoloc-icai.  Processes  of  Brighx's  Disease.  Ey  HoRsr 
Oertei.,  \r.  D,  Director  of  the  RusseE  Sage  InstiTate  of  FathcLcay.  XeTsrYork.  Ccnt-a 
of  227  pages,  with  44  text-cuts  and  6  colored  plates.     Cloth.  $5.00  net  Deconber.  I9ia 

Arnold's  Medical  Diet  Charts 

METtCAL  Diet  Charts.  Prepared  by  H.  D.  AR:fOLD.  M.  D..  Dran  of  Hanriad 
Graduate  Medical  School.  Boston.  Single  charts.  5  cents :  5a  chans,  5^.oo  net ;  5Q0 
charts,  $rS.ao  net :  looc  ciiarts,  $_;o.Qo  net. 

Eggleston's  Prescription  Writing 

ESSENTIALS  OF  Frescreftion-  Wrtti^-G.  By  C\B.Y  EgglestoN".  M.  D.,  Jnstrnctor 
in  Pharmacolosv.  Cornell  Uniyeratv  MedicaL  SchaoL  romo  cf  125  pages.  L.oth  5x.aa 
j^gj^  ""  PnWirfrea  Septenifrsr.  iai3 


1 6  SAUNDERS'  BOOKS  OA^  PRACTICE,  Etc. 


Slade's  Physical  Examination  and  Diagnostic  Anatomy 

Physical  Examination  and  Diagnostic  Anatomy.  By  Charles  B.  Slade, 
M.  D.,  formerly  of  University  and  Bellevue  Medical  School.  i2mo  of  150  pages' 
illustrated.  Second  Edition— published  September,  1916.  Cloth    $1.2- net' 

Abbott's  Medical  Electricity 

Medical  Electricity.  By  George  Knapp  Abbott,  M.  D.,  Dean  and  Pro- 
fessor of  Physiologic  Therapy  and  Practice,  College  of  Medical  Evangelists,  Loma  Linda, 
California.      1 2mo  of  132  pages,  illustrated.     Cloth,  ^1.25  net.  April,  1915 

Stevens'  Practice  of  Medicine  New  (loth)  Edition 

A  Manual  of  the  Practice  of  Medicine.     By  A.  A.  Stevens,  A.  M.,  M.  D., 

Professor   of    Pathology,    Woman's   Medical    College,    Phila.  Specially   intended  fot 

students  preparing  for  graduation  and   hospital  examinations.  Post-octavo,  629  pages, 

illustrated.      Cloth,  $2.50  net.  Published  July,  1915 

Saunders*  Pocket  Formulary  New  (9th)  Editioe 

Saunders'  Pocket  Medical  Formulary.  By  William  M.  Powell,  M.  D. 
Containing  1831  formulas  from  the  best-known  authorities.  With  an  Appendix  con- 
taining Posologic  Table,  Formulas  and  Doses  for  Hypodermic  Medication,  Poisons  and 
their  Antidotes,  Diameters  of  the  Female  Pelvis  and  Fetal  Head,  Obstetrical  Table, 
Diet-list,  Materials  and  Drugs  used  in  Antiseptic  Surgery,  Treatment  of  Asphyxia  from 
Drowning,  Surgical  Remembrancer,  Tables  of  Incompatibles,  Eruptive  Fevers,  etc., 
etc.     In  flexible  leather,  with  side  index,  wallet,  and  flap,  ^1.75  net.  January,  1909 

Deaderick  on  Malaria 

Practical  Study  of  Malaria.  By  William  H.  Deaderick,  M.  D.,  Member 
American  Society  of  Tropical  Medicine ;  Fellow  London  Society  of  Tropical  Medicine 
and  Hygiene.  Octavo  of  402  pages,  illustrated.  Cloth,  ^^4.50  net;  Half  Morocco,, 
$6.00  net.  Published  Novembes,  1909 

NileS    on    Pellag(ra  second  Edition— January,  1916 

Pellagra.        By    George    M.   Niles,    M.  D.,   Gastro-enterologist  to  the  Georgia 
Baptist  Hospital,  Atlanta.     Octavo  of  225  pages,  illustrated.      Cloth,  $3.00  net. 

Hinsdale's  Hydrotherapy 

Hydrotherapy.  By  Guy  Hinsdale,  M.  D.,  Fellow  Royal  Society  of  Medicine 
of  Great  Britain.      Octavo  of  466  pages,  illustrated.     Cloth,  $3.50  net.  August,  1910 

Todd*s  Clinical  Diagnosis  Third  Edition-October.  1914 

Clinical  Diagnosis  :  A  Manual  of  Laboratory  Methods.  By  James  Camp- 
bell Todd,  M.  D.,  Professor  of  Pathology,  University  of  California.  i2mo  of  5S5 
pages,  illustrated.     Cloth,  $2.50  net. 

This  book  gives  you  the  exact  tecknic,  the  precise  procedure  to  fellow  down  to  the  smallest  detail. 
An  extremely  important  section  is  that  on  the  use  of  the  microscope,  giving  you  the  various  parts,  how 
to  prepare  the  material,  make  slides,  and  interpret  the  findings.  The  third  edition  has  been  brought 
right  down  to  the  minute.  The  contents  include  70  pages  on  the  therapeutic  use  of  vaccines  and  sero- 
diagnosis,  taking  up  the  preparation  of  autogenous  vaccines,  Abderhalden's  serum  test  for  ectopic  preg- 
nancy, the  urease  methods  for  urea,  the  Rimini-Burnam  test  for  formaldehyd,  Huntoon's  method  for 
spores,  Bonder's  stain  for  diphtheria  bacilli,  and  the  luetin  reaction. 

"A  distinct  improvement  on  many  of  its  predecessors  of  similar  scope.  It  deals  with  all  the  examina- 
tions which  the  clinician  may  have  to  undertake  in  the  course  of  his  work.  "—British  Medical  Journal. 


COLUMBIA  UNIVERSITY 

This  bQok  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

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SFp  ?    m 

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Annex 


